1ST CASE WRITE-UP

SURGICAL POSTING
(ROTATION 5)

NAME: ANWAR ASYHRAFF BIN ABDUL AZIZ

COLLEGE ID: 57260211124
GROUP 6A
ACADEMIC ADVISOR:
DATUK DR SUBRAMANIAM A/L MUNIANDY

CASE 1
CLERKING
Identification Data
Name

Sudak Dula Miah

HRPB I.D

HRPB 522766

Age

24 years old

Sex

Male

Race

Bangladeshi

Marital status

Single

Triage

Yellow zone

Initial Presentation
Generalized abdominal pain for one day.

History of Presenting Illness

He was well until he was admitted to Hospital Raja Permaisuri Bainun on 25 th June
2015 at 3.15 pm for severe generalized abdominal pain for one day. Patient described
pain can be felt at all part of the abdomen. The pain is a sudden onset and pricking in
nature. The pain radiates to the right iliac fossa. There was no relieving and
exacerbating factors. The pain continuously presence throughout the day. The severity
of pain was 7 over 10. After that, patient had developed fever associated with chills
and rigor. Patient claimed after he had pain during the first episode, he had vomited
three times associated with feeling nausea prior to admission. The vomitus mainly
containing indigested food particles. Taste of the vomitus is exactly the same as the
taste of food and the volume of the vomitus is about the same as amount of food as he
took. He usually vomited soon after taking meals. No weight loss and no loss of
appetite suggestive malignancy, no heartburn, no changes in colour stool, no loin to

groin pain, no difficulty in passing urine suggestive genitourinary disease, no

diarrhoea and no altered bowel habit.

Past Medical History

No comorbidities
He has never hospitalized before.

Past Surgical History

He had never undergone any surgery before.

Drug History
Not on any types of medications.
No known drug/ food allergy.

Family History
No history of malignancy running in his first degree relatives.
Father and mother died due to unknown cause. He is 3rd among 5 siblings. None of his
siblings had the same kind of problem like him.

Social History
He is an immigrant from Bangladesh who came here to work for Kilang as a factory
worker. He didnt smoke as well as consume alcoholic drinks. He didnt complete his
study due to his familys financial constraint. His financial status with his current
salary is adequate to support his monthly expenditure.

PHYSICAL EXAMINATION
General

Patient is alert and conscious.

Vital signs

Temperature - 38 degree celcius

Blood pressure 145/90 mmHg

Pulse rate 133 beats/min

Respiratory rate 20 breaths/min
Capillary filling time is less than 2 seconds.
Pain score is 7/10
Hands

No clubbing, no contracture, no tobacco staining, no

leukonychia, no koilinychia. Palm is warm.

Eyes

No pallor, no jaundice.

Oral

Oral hygiene is good. No coating. Hydration status is good.

Abdominal Examination :

Inspection

Abdomen moves with

respiration. No previous scars

Palpation

On superficial palpation, the

abdomen is hard and there is
tenderness at right iliac fossa.
Rovsings sign is positive

Percussion

Liver span is normal at 11 cm.

Traubes space is dull. Shifting
dullness and fluid thrill was
negative.

Auscultation :

Bowel sound can be heard

between 1 to 5 mins.

Investigation
Full blood count - Normal
Abdominal X-Ray Normal
Abdominal Ultrasonography - Normal

Differential Diagnoses

Acute urinary tract infection

Ureteric calculi

Provisional Diagnosis
Acute perforated appendicitis

Management

Keep nil by mouth

Maintain hydration status

Nasogastric suction

Antibiotic therapy for 3 to 5 days with Second Generation Cephalosphorin.

Planned for laparoscopic appendicectomy

Outcome of the Patient

Patient was admitted to surgical ward

Discussion
Acute appendicitis is acute inflammation and infection of the vermiform appendix,
which is most commonly referred to simply as the appendix. The appendix is a blindending structure arising from the cecum. Acute appendicitis is one of the most
common causes of abdominal pain and is the most frequent condition leading to
emergent abdominal surgery in children. The appendix may be involved in other

infectious, inflammatory, or chronic processes that can lead to appendectomy;

however, this article focuses on acute appendicitis. Appendicitis and acute
appendicitis are used interchangeably.
Common symptoms of acute appendicitis include abdominal pain, fever, and
vomiting. The diagnosis of appendicitis can be difficult in children because the classic
symptoms are often not present.

A delay in the diagnosis of appendicitis is associated with rupture and associated

complications, especially in young children. Improvements in rupture rates have been
made with advanced radiologic imaging. Appendicitis is a clinical diagnosis with
imaging used to confirm equivocal cases.

The definitive treatment for appendicitis is appendicectomy. Initiation of antibiotics

upon diagnosis is important to slow the infectious process and help prevent
progression of a nonperforated appendix. Key to any evaluation and treatment plan
are the following: relieve the patient's pain and discomfort early and consistently;
communicate with the patient and family about the plans; repeat the examination
often; adjust the differential diagnosis as appropriate; and keep the patient for
observation if a firm diagnosis is not made.

The most widely used antibiotic regimen is the combination of ampicillin,

clindamycin (or metronidazole), and gentamicin.