1. Hannah Tanbonliong

2. J.C. 36/M December 24, 1975 Filipino Catholic Makati City Date of Admission: March 21, 2012

3. 2 days PTA Epigastric pain Non-radiating Crampy HNBB  no relief

4. 1 day PTA Epigastric pain Radiating to RLQ Crampy No N/V No fever No change in BM Polymedic Hospital  WBC 15.35 A

5. No DM, HTN, CA, PTB, cardiac, kidney, or lung diseases. No known allergies. No previous surgeries or hospitalizations.

6. + Stroke No HTN, DM, CA, cardiac, kidney or lung diseases.

7. 3 rd year college Call center agent 10-pack-year smoker 4-5 bottles of beer per week No illicit drug use

8. General: No changes in weight, change in appetite, easy fatigability, or fever. Skin: No rashes, lumps, sores, or itchiness. Head, Eyes, Ears, Nose, Throat (HEENT). No dizziness, hearing loss, diplopia or headaches. Neck: No enlarged lymph nodes. No swollen glands. Respiratory: No dyspnea or cough.

9. Cardiovascular: No chest pain, palpitations, or syncope. Gastrointestinal: No nausea, diarrhea, constipation. Urinary: No dysuria, hematuria or flank pain. Musculoskeletal: No muscle pain, joint pain or swelling. Endocrine: No excessive thirst, heat intolerance, polyuria or cold intolerance.

10. Alert and coherent. GCS15. Vital Signs: Height of 160cm Weight of 69.5kg BMI of 27.1 kg/m2 (overweight) BP 110/60 HR 80 bpm and regular RR 23 breaths per minute Temp 36C

11. Skin: Warm, normal skin color, no rashes or lesions. Head, Eyes, Ears, Nose, Throat (HEENT): Ancteric sclera, pink palpebral conjunctiva. EBRTL 2mm No tonsillo-pharyngeal congestion. Neck: Trachea is midline. No enlarged lymph nodes. No nuchal rigidity.

12. Pulmonary: Normal shape of chest and movement. No scars, birthmarks, discolorations. Normal respiratory expansion/symmetric. No masses or tenderness. Clear breath sounds, no crackles or wheezing. Cardiac: Apex beat at the 5 th left ICS, MCL. Distinct S1 and S2, no murmurs. Increased heart rate with normal rhythm. No heaves or thrills.

13. Abdomen: Flat abdomen, no scars. Normoactive bowel sounds. Tympanitic on percussion of all quadrants. Liver span of 10 cm MCL. No hepatosplenomegaly. Soft. Tender on palpation of RLQ, no masses, liver edge is smooth. (-) Murphy's, (-) rebound tenderness, (+) Rovsing’s, (-) Obturator sign. No CVA tenderness.

14. DRE: No skin tags, visible lesions. Good sphincter tone. No masses, fissures or impacted fecal matter. No blood on examining finger. Extremities: No lesions, edema, cyanosis or clubbing of finger nails. With good turgor. Full and equal pulses on all extremities.

15. 36/M Epigastric  RLQ pain + Direct Tenderness + Rovsing’s Sign

16. Acute Appendicitis

17. Rule In Rule Out Appendicitis Pain migrating to the RLQPain migrating to the RLQ Sudden onsetSudden onset (+) Rovsing’s Sign(+) Rovsing’s Sign (+) Direct Tenderness(+) Direct Tenderness Meckel’s Diverticulitis Same clinical picture as appendicitis Acute Epididimytis/ Testicular Torsion MaleMale Sudden onset of painSudden onset of pain (-) groin pain, inguinal pain(-) groin pain, inguinal pain (-) scrotal erythema/ warmth on touch(-) scrotal erythema/ warmth on touch * Cremasteric reflex* Cremasteric reflex Nephrolithiasis Midureteral calculi can cause pain in the RLQ and mimic appendicitis (-) urinary signs(-) urinary signs (-) hematuria(-) hematuria Pain migration (left to Right), peritoneal signsPain migration (left to Right), peritoneal signs

20. Acute inflammation of the appendix Common cause of acute abdomen at the 2nd to 4th decade of life (mean of 30 y.o.)

21. Stages: Obstructive Suppurative Gangrenous Perforated

25. RLQ pain, maximal at McBurney’s point Peritoneal signs: Rebound tenderness Rovsing’s sign Obturator’s sign Psoas sign Dunphy’s sign Markle’s sign Guarding

28. CBC WBC> 10,000 per mm 3 seen in 80% of cases Low predictive value, low specificity Urinalysis C-Reactive protein new suggested laboratory parameter Levels > 0.9mg/dL All laboratory tests together--”highly sensitive” (97-100% sensitivity)

29. UTZ blind-ending, nonperistaltic bowel loop from the cecum POSITIVE: >6mm in anteroposterior direction Identify appendicolith Thickening of the wall with periappendiceal fluid NEGATIVE: Non-compressible appendix, measuring <5mm

30. UTZ Sensitivity: 55-96% Specificity: 85-98% Can identify abscess Fast No contrast needed Can be used in children and pregnant women

31. UTZ False-positive Periappendicitis from surrounding inflammation Other structures mistaken as the appendix User-dependent Obese patients

32. CT Scan Dilated appendix (diameter > 5mm) Thickened wall Fecalith 92-97% sensitivity, 85-94% specificity 75-95% PPV, 95-99% NPV

33. CT-Scan Expensive Radiation exposure Allergy to IV contrast Not available in all institutions*

35. Appendectomy Open Laparoscopic Less pain Less hospital stay Shorter admission time

36. 7x2cm appendix, non-suppurative