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clinical
Presentation
Dr Rahul Sikder
Intern doctor
Department of Urology
Diabteic Association Medical College, Faridpur
Particulars of the patient :
• Name:Md Taibur Rahman
• Age:19 years
• Sex-Male
• Marital status :Unmarried
• Religion: Islam
• Bed no-C-1452
• Adresss:Zumarkanda,Kawlebera,Bhanga,Faridpur
• Date of admission-18.1.24@ 7.30 pm
• Date of examination -18.1.24@ 7.45 pm
Chief complaints :
• Severe pain in right lower abdomen for 1 day.
• Anorexia for 1 day
History of presenting illness:
• According to the statement of thw patient, he was reasonably
well 1 day back. Then he has been developed severe sudden
pain in right lower abdomen.Pain is constant,.aggravated by
movement, relives by taking medication. He also complains of
anorexia for 1 day.He is known case of acute appendicitis.
There is no history of fever,vomiting. He is non diabetic,
normotensive. There is no heamtemesis,malena,hemoptysis.
For above these complaints, he has been got admited to
DAMCH for better management.
History of past illness :
• He was admitted into DAMCH under Professor of surgery of
unit-2 with same complaints.where he was diagnosed as acute
appendicitis. He was under conservative management. Then
after conservative management, when he felt better,then he
was discharged and no appendicectomy was done.
Family history
• All her family members are apparently
healthy.
Drug history
• He took Napa(Parectamol)(500mg) for pain
Allergic history :
• He is not allergic to dust,pollen,food or drugs.
Immunisation history :
• He is immunised as per EPI schedule and 3 dose of
covid-19 vaccine
Socio-economic history :
• He belongs to middle class family, lives in building,uses
sanitary latrine, takes water from tubewell.
Personal history :
• He is non smoker, non alcoholic, doesn’t consume betel nut.
General examination :
• Appearance : Ill looking
• Body built: Average
• Co-operation: Co-oprative
• Decubitus- On choice
• Anemia-Absent
• Jaundice-Absent
• Cyanosis-Absent
• Leuconychia- Absent
Cont….
• Koilonychia-Absent
• Clubbing-Absent
• Lymph node-not enlarged
• Hair distribution : normal
• Bony tenderness:Absent
• Pulse-84 beats/min
• Respiratory rate-16 breaths /min
• Temperature -98*F
Gastrointestinal examination :
• Upper Git:
• Mouth, oral cavity,buccal mucosa –normal
• Abdomen proper:
• Inspection:
• Shape:Scaphoid
• Umbilicus: Centrally placed,inverted,transverse slit
• There is no abdominal distention, flank fullness,no engorged vein,no
visibile peristalsis.
Palpation:
• Superficial – Tenderness,raised temperature is present in the right
illac fossa.There is no muscle guardness and muscle rigidity.
• Deep palpation- There is no organomegaly
• Duodenal point tenderness –absent
• Murphy’s sign- negetive
• Macburney’s point tenderness – present
• Rebound tenderness – present
• Pointing sign – present
• Fluid thrill- absent
Percussion
• Percussion note-tympanic
• Shifting dullness-absent
Auscultation
• Bowel sound present
Respiratory system
• Inspection- Shape of the chest is bilaterally symmetrical and
elliptical, there is no chest deformity, restricted movement, scar
mark, procedure marks, engorged vein
• Palpation- Trachea is placed centrally, Apex beat is situated at 5th ICS
just 10 cm away from midline, Total lung expansibility –Normal
• Percussion-
• Percussion note-Resonant
• Upper border of liver dullness present-Right 5th ICS
• Cardiac dullness- present
Cont…
•Auscultation-
• Breath sound-Vesicular, There is no ronchi,
crepitaion, pleural rub
Cardiovascular system
• Inspection- There is no apical impulse, chest deformity, engorged
vein, scar mark
• Palpation- There is absence of palpable p2,thrill,left parasternal
heave
• Auscultation- 1st and 2nd heart sound is audible in all auscultatory
area. There is no murmur, pericardial rub
Nervous system
• Higher psychic function test –normal
• Motor function test –normal
• Sensory function test–intact
• Cranial nerve-Intact
• There is no signs of meningeal irritation
• Other systemic examinations reveals no abnormalities.
Salient features
Mr. Md Taibur Rahman, student,unmarried, hailing from Bhanga,
Faridpur, has been got admited into DAMCH with the complaints of
sudden severe pain in the right illiac fossa.He is known case og acute
appendicitis. Pain is aggravated by movement and relieved by taking
medication.
On my general examination, pulse-84 beats/min,Bp-120/70 mmHg,RR-
16 breaths/min,Temperature -98* F.
On my systemic examination, Macburney’s point tenderness present,
rebound tenderenss present.
Others systemic examinations reveals no abnormalities.
Provisonal diagnosis:
• Recurrent appendicitis
Differential diagnosis
• Right sided Ureteric stone
• Urinary tract infection
• Mickels Diverticulitis
Investigation:
• Ultrasonogram of whole abdomen special attentin to RIF
• Complete blood count
• Serum creatinine
• Urine RME
• Ecg
• Chest X-ray P/A view
Name Date Results
USG of whole 18.1.24 Right illac fossa shows
abdomen special blind ended,non
attention to RIF compressible,
aperistatic,Tubular,
S. Creatinine 19.1.24 1.15 mg/dl
Urine RME 19.1.24 Albumin(+)
Puss cell-plenty
Epethelial cell-5-7/HPF
Name Date Results
Complete blood count 19.1.24 Hb-13.8 g/dl,ESR-35
mm in 1st hour,TWBC-
12160/cmmm
,Cir.Eosinophil count-
480/cmm,DC of
neutrophil-73%
ECG 19.1.24 Normal
Operation note:
• Name:Open appendisectomy
• Date and time: 21.1.24 @12.55 pm
• Indication- Recurrent appendicitis
• Surgeon-Professor of Urology
• Assistant- Medical officer of Urology,Intern doctor of
Urology
• Anesthetist : Assistant Professor of anesthesia
• Anesthesia : SAB
Operation procedures and
findings
• With all available aseptic preacautions under spinal anesthesia, in supine positon,
skin is incised at RIF.Two layers of superficial fascia are cut.External oblique
apponeurosis is opened in the line of incision. External oblique aponeurosis is
opened in the lineof incision. Internal oblique and transverse muscles are split in
theline of fibres. Peritoneum is opened in the line of incision. Caecum is identified b
taeniae, and ileocaecal junction. Omentum when adherent is separated. Appendix i
held with Babcock's forceps.Mesoappendix with appendicular artery is ligated. Usin
threador silk, a purse-string suture is placed around the base of theappendix. Base o
the appendix is crushed with artery forceps and transfixed using vicryl (absorbable).
Appendix is cut distal thesuture ligature and removed. Stump is cleaned with
antiseptics.Purse string suture is tightened so as to bury the stump.
Picture of the operation
Resected specimen of appendix
after operation
Post operative order
• NPO for 6 hours
• Inf.5% DNS(1L)+Inf. H/S(1L)+Inf.N/S(1L)-I/V @30 drops/min
• Inj.Ceftriaxone (1gm)- 1vial I/V stat and 12 hourly
• Inj Tramadol Hydrochloride (100mg)-1 amp I/M stat and 12 hourly
• Inj.Nalbuphine -1 amp I/M stat
• Inj Emistat-(8mg/3ml)- 1 amp I/v stat and 12 hourly
• 0xygen inhalation -SOS
Treatment of 1st POD
• Diet –Normal
• Inj. Ceftriaxone -1 vial I/V 12 hourly
• Tab Paracetamol (665mg)-1+1+1(P/C)
• Cap Progut(20mg)-1+0+1(A/C)
• Tab Domperidon(10mg)-1+1+1(A/C)
• Syp . Sodium Picosulfate-2 TSF at night
• Supp. Diclofenac sodium(50mg)-1 stick per rectal 12 hourly
Treatment on discharge
• Cap. Cefuroxime (400mg)-1+0+1 for 7 days
• Cap. Flucloxacilin(500mg -1+1+1+1 for 5 days
• Tab Metronidazole(400mg)-1+1+1 for 5 days
• Tab Domperidone(10mg)-1+1+1 before meal
• Tab Paracetamol (665mg)-1+1+1 for 5 days after meal
• Cap. Esomeprazole (20mg)-1+0+1 for 15 days
• Syp Sodium Picosulphate- 2TSF before bedtime-1 Phil
• Oint. Mupirocin –apply locally at affected site for 14 days
Advice
• Regular intake of prescribed drug
• After 3 days come to hospital and stiches should be cut off
• After 7 days, with prescription come to surgery OPD
