– History –
- CC: most likely will present as LLQ pain:
- Onset: first time? When\duration? Sudden\gradual? Continues\intermittent? Getting worse? Prev URTI\sore throat?
- Location: where? Started peri-umbilical? Does it radiate anywhere else (groin)?
- Character: colicky, dull, stabbing?
- Aggravating\relieving factors: food? Position? Coughing? Pain killers?
- Severity: 1-10 scale? Wakes you up from sleep? Interfering w\ ADL?
- Associated sx:
- Constitutional: fever, chills, wt loss, loss of appetite
- GI: jaundice, abdominal swelling\distension, N\V, diarrhea\constipation, blood in stool?
- Urine: burning urination, change in color, bloody?
- Chronic ds (HTN, DM, DLP)
- GI: IBD, diverticulosis, IBS
- GU: UTI, stones
- Surgery, hospitalization, trauma
- Blood transfusions, IV drug use, tattoos
- Menstrual Hx
- Similar complaint?
- Same diseases as in PMHx?
- Social Hx:
- Occupation, marital status, children?
- Smoking, alcohol, recreational drugs?
- Travel Hx
- Diet, exercise
– Abdominal Physical Exam –
- WIPE, blah blah 🙂
- “Take vital signs”
- Position: flat, arms on the side, pillow below the head
- Proper exposure: from xiphoid to mid-thigh
- General inspection of the pt and surroundings
1. Inspection: (stand at the end of the bed)
- Symmetry and contour
- Abdominal distention + flank fullness
- Scars, skin changes\discoloration, rashes, straie
- Obvious masses or swelling
- Dilated veins\caput medusa
- Visible pulsations
- Umbilicus (inverted\everted?)
- Hernias (ask pt to cough)
2. Palpation + percussion: (ask pt if they have any pain?)
- Superficial and deep palpation: “abdomen soft and lax, no tenderness, no masses, no peritoneal signs”
- Special signs of appendicitis:
- Rebound tenderness
- Dunphy sign: ask pt to cough -> increased pain
- Rovsing sign: palpate left side (which moves gas over) -> pain in RLQ
- Obturator sign: flex knee + internally rotate hip -> RLQ pain [pelvic appendix]
- Iliopsoas sign: extend hip -> RLQ pain [retrocecal appendix]
- Bowel sounds
- Bruits: Aortic, renal, femoral
4. To complete:
- Digital rectal exam (PR)
- Genital exam
- Fecal occult blood test
– Investigations –
- Remember; appendicitis is a clinical diagnosis!
- CBC: to check for leukocytosis, neutrophilia
- Renal and liver function tests
- Amylase + lipase
- AXR: fecalith, bowel obstruction
- US: esp in children and ladies in child-bearing age. Findings:
- Dilated (> 6 mm diameter), non-compressible appendix
- Hyper vascular wall
- Surrounded by inflamed fat
- CT: more accurate. Findings:
- Dilated (> 6 mm diameter)
- Thickened + enhanced wall
- Peri appendicular fat stranding
- Localized ileus or ceccal wall thickening
– Management –
- Appendectomy: either open or lap, unless in certain pts, where lap appendectomy is more preferred:
- Obese pts
- Ladies in child-bearing age
- Elderly pts
|– Evaluation of abdominal\pelvic organs
– ↓ Post-op stay + pain
– Earlier recovery -> earlier return to activity
– Better cosmetic results
– Requires skilled surgeon
- If you find a normal appendix? take it out and look for Meckel’s diverticulum