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Appendicitis

Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓

 

Doctor Instruction:


You are a doctor currently working in emergency medicine. Your next patient is Andy Lau – a 23-year-old male presenting with abdominal pain. Please take a history and perform a relevant examination.



 

Patient History:


Andy Lau - 23-year-old gentleman - Master Student.


You experienced sudden tummy pain 12 hours ago. This is getting worse, so you have decided to go to the A&E to check it out. The pain is centralised at the lower right quadrant of your tummy. You describe this as excruciating sharp pain – rate it as 8/10. Moving around and touching the site of pain makes it more painful. You have tried to take some paracetamol, but it doesn't seem to work that much.


If asked specifically, the pain you remember started only around your belly button and moved to the lower right quadrant 3-5 hours ago.


You have lost your appetite but try to eat/drink whenever you can. You are experiencing both nausea and vomiting. No blood in the vomit - just normal food you have eaten. You feel quite warm + feverish, and you notice your face has gotten redder than usual. You haven't been to the toilet to empty your bowel for >24 hours. No blood in the stool. Your waterworks are normal.


Ideas, Concerns, Expectations:

  • Yesterday, you ate some raw sashimi with your mates at a new Japanese restaurant in town. You are not sure if you have caught an infection because of this. You know you have a weak stomach compared to your peers, and that's why you are the only one feeling unwell. Your other mates are well and healthy. You are very concerned as this pain is no longer tolerable. You can't even move and do anything. You want some morphine to ease the pain.


Past Medical History:

  • Crohn's disease, asthma


Drug History:

  • Steroids for Crohn’s disease, salbutamol inhaler as required.

  • NKDA


Family History:

  • Mother has Crohn’s disease.


Social History:

  • Currently, a master's student studying architecture.

  • You are currently living in a flat shared with your mates.

  • You are not managing at home at the moment.

  • You do not smoke.

  • You drink around two cans of beer every weekend with the lads.


 

Examination Findings:

  • Inspection: unwell, in pain, sweating, flushed face, doesn’t want to move

  • Lower right quadrant tenderness – McBurney’s sign

  • Rebound tenderness at right iliac fossa +/- Guarding

  • Reduced bowel sounds

  • Psoas sign positive (right)

  • Rovsing’s sign positive


 

Differentials:

  1. Appendicitis (classic history and examination findings)

  2. Appendix mass

  3. Gastroenteritis (fever + recent uncooked meal)

  4. Crohn’s disease flare (PMH + FH)


 

Investigations:


Bedside:

  • Observations

  • Stool MCS– rule out gastroenteritis


Bloods:

  • FBC – mild leucocytosis in appendicitis

  • U&E – dehydration from vomiting

  • LFT – baseline + rule out other causes of abdominal pain

  • CRP – inflammation

  • Blood culture - infection

  • Group and Save - to prepare for theatre


Imaging:

  • Contrast CT Abdomen – appendicitis, rule out other pathology i.e. bowel obstruction/perforation

  • US – appendicitis / ovarian cysts if female + first line for young patients


Other investigations to consider:

  • Urinalysis - to rule out UTI as cause for pain

  • Pregnancy test if female (Ectopic pregnancy)

  • Abdominal MRI


 

Management:

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