Kasus 6a Appendisitis April 2016

8/16/2019 Kasus 6a Appendisitis April 2016

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Medical Education Unit 2016

Gastrointestinal System- 6 th Case

CASE VI Page 1

BLOCK : GASTROINTESTINAL SYSTEM

SEMESTER : IV MODUL : UPPER GASTROINTESTINAL TRACT UNIT : 6th WEEK

SCENARIO TYPE : NARATION, MULTILEVEL PROBLEM SCENARIO FORMAT : PROBLEM PACK + SOEP TOPIC : ACUTE ABDOMEN DISORDERS TO BE LEARNED :

Peritonitis TBC (pediatrics) 4

Ileus 3B

Appendicular abscess 3B

Acute appendicitis 3A

Umbilical hernia (pediatrics) 3A

Diaphragmatic hernia 2

Hiatus hernia 2

Inguinal hernia, direct and indirect 2

Femoral hernia (surgery) 2

Epigastric hernia 2

Incisional hernia 2

Umbilical hernia 2

Peritonitis TBC (pediatrics) 2

Abscess in puch of Douglas 2

Perforation 2

Intestinal atresia 2

Meckels' diverticulum 2Umbilical fistula, omphalocele-gastroschisis

2

Malrotation 2

Diaphragmatic hernia (congenital,pediatrics)

2

Acute abdomen (pediatrics) 2

Ileus (pediatrics) 2

Intussusseption (pediatrics) 2

Hirschsprung's disease (pediatrics) 2

Peritonitis pancreatitis 1Malrotation 1

SYMTOMPS TO BE LEARNED :

DAFTAR MASALAH KESEHATAN SISTEM PENCERNAAN SKDI 2012

NO DAFTAR MASALAH KESEHATAN

1 Mata kuning 15 Bibir sumbing

2 Perut berbunyi 16 Berak berlendir dan

berdarah

3 Mulut kering 17 Sulit menelan

4 Benjolan di daerah perut

18 Berak berwarna hitam


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CASE VI Page 2

5 Mulut berbau 19 Cegukan/hiccups

6 muntah 20 Berak seperti dempul

7 Sakit gigi 21 Nyeri perut

8 Muntah darah 22 Gatal daerah anus

9 Gusi bengkak 23 Nyeri ulu hati

10 Sulit berak/sembelit 24 Nyeri daerah anus11 Sariawan 25 Perut kram

12 Tidak bisa berak 26 Benjolan dianus

13 Bibir pecah-pecah 27 Perut kembung

14 Diare 28 Keluar cacing

CASE TITLE : Miss. Poppy’s emergency condition

REFERENCES :1. Avunduk, Canan, Manual of Gastroenterology: Diagnosis and Therapy, 3rd

edition, Lippincot Williamms & Wilkins; 20022. Despoupolus A, Sibernagl S. Color Atlas of Physiology. 5th ed. Stuttgart New

York: Thieme; 2003

3. Graham P. Butcher, Gastroenterology: an illustrated colour text. ChruchillLivingstone; 2003

4. Guandalini S, Textbook of pediatric Gastroenterology and nutrition. Taylor andFrancis; 2004

5. Guyton AC, Hall JE. Textbook of Medical Physiology. 11th ed. Philadelphia:Saunders; 2000

6. Harrison’s. Principle of Internal Medicine. 17th ed. USA: McGraw Hill; 20087. McPhee J Stephen , Pathopgysiology of Disease: an Introduction to clinical

Medicine, 2nd

edition, Appleton & Lange

CASE VI, 2 SESSIONS

Topic: Acute abdominal pain

ANAMNESIS

A thirty years old woman had right lower abdominal pain. At the first time she felt an

epigastric pain which moved towards the right abdomen within several hours. The pain

became steady and more severe at the moment. She also got fever recently. She noted ofnausea and vomiting with normal appetite. There was neither diarrhea nor changing in bowel

habit.

Her menstruation is regular (every 28 days) and her last menstruation was 27 days ago. She

never had any abdominal surgery before. She denied of having recent abdominal injury. She

had neither history of abnormal micturition nor vaginal discharge. She has 2 healthy

daughters.

What is the patient’s problem?

Student is expected to identify:

Chief complaint: right lower abdominal pain Onset, characteristics and accompanying symptoms of the abdominal pain


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CASE VI Page 3

The conversion of initial visceral pain into somatic pain

Pathophysiology of acute abdominal pain

List of your hypothesis ?

Differential diagnosis of right abdominal pain in female patients:

1. Acute appendicitis2. Ectopic pregnancy3. Ovarial Cyst torsion4. Mittelschmerz5. Renal/ureteral colic6. Mesenteric adenitis: tuberculosis, non tuberculosis7. Ileitis terminalis8. Diverticulitis Meckel9. Adnexitis10. Tubo-ovarial abscess11. Abdominal injury12. Malignancy of the caecum: carcinoma, lymphoma, carcinoid

PHYSICAL EXAMINATION

The patient was in the Emergency Unit.

She looked pale and quite perspiring and in deep pain. The blood pressure is 100/60 mm Hg,

the pulse rate was 108x/minutes and her body temperature was 38,3C. The respiratory rate

was 26/minutes. The conjunctiva’s not anemic.

The physical examination was confined to the abdomen. On inspection it’s not distended.Tenderness and rebound tenderness were elicited at the right lower quadrant. There’s neither

scar at the abdomen, nor any mass or muscular rigidity but pain was noted on Mc Burney.

The bowel sound decreased. The liver, gall bladder and spleen were not palpable. Psoas sign,

Rovsing’s sign were positive, as well as Cough sign, while obturator’s sign was negative.

There’s no abnormality at the flank region.

On digital rectal examination sphincter tone was, intact mucosa, no collapsed ampulla. The

pain was elicited at the 9 to 12 o’clock position. There’s no abnormality in the Douglas

cavity, no pain on portio motion. Vaginal examination was within normal limit.

How does this information change your hypotheses?Student is expected to identify:

Typical physical signs of acute appendicitis.

Diagnostic exclusions of gynecological problems

What further information do you need?

LABORATORY FINDINGS:

The doctor in charge ordered additional diagnostic information and tests and bellow’s theresults:


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CASE VI Page 4

Blood tests: Normal values

Hb: 12,5 gr % 12.3 – 15.3 mg/dL

WBC: 16.200/mm3 4 400 – 11 300 /

Urine sediment:

leucocyte: 3-4, Not detectableerythrocyte: 1-2, Not detectable

no bacteria. Not detectable

Pregnancy test: negative

USG impression: The uterus and both adnexas were normal. The bladder was normal too.

The appendix was found at the compression test and there were neither periappendix mass

nor abscess. There was no sign of intraperitoneal fluid collection.

The doctor on duty decided to perform emergency appendectomy, after i.v. fluid and empiric

antibiotics treatment are administered.

What is your impression?


Laboratory results of acute appendicitis:o WBCo Urinalysis

The need of pregnancy test


The role of diagnostic imaging: USG, Plain abdominal x-ray

Steps taken to diagnose acute appendicitis

Initial management of acute appendicitis

Surgical management of acute appendicitis

During surgery, you find the appendix is gangrenous, with size of 10 cm length and 1.5 cm in

diameter and is filled with fecolith at the proximal third. You also find bad smell pus

collection surrounding the appendix approximately 5 cc.

.

Theme:

The week will center on acute appendicitis and acute abdominal pain.

Learning objectives:

At the end of the week, the student will be able to:

REVIEW BASIC SCIENCE

IMMUNOLOGY OF GI SYSTEM

PATHOLOGY OF ACUTE ABDOMEN:

APPENDICITIS

1. Describe the patho-physiology of abdominal pain2. Compare and contrast between somatic pain and visceral abdominal pain


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CASE VI Page 5

3. Explain the developmental anatomy of the appendix4. Describe the anatomy of the appendix5. Explain the blood supplies and lymphatic drainage of the appendix6. Describe the microstructures of the appendix7. Explain the definition of appendicitis

8. Explain the histo-pathological features of appendicitis, including acute, chronic and acuteexacerbation on chronic appendicitis.

9. Explain the histo-pathological features of carcinoid of the appendix.10. Discuss the patho-physiology of appendicitis11. Compare and contrast the histo-pathological features and clinical pictures between acute

appendicitis and chronic appendicitis.

12. Describe the natural courses and complications of appendicitis.13. Describe the signs and symptoms of acute appendicitis14. Discuss the differential diagnosis of acute appendicitis15. Appraise the steps taken to diagnose acute appendicitis16. Discuss the management of simple acute appendicitis, and complicated appendicitis

17. Explain the role of abdominal imaging in diagnosing appendicitis

PERITONITIS18. Explain the concept of peritonitis, Sepsis, and Systemic Inflammatory Responses

Syndrome

19. Describe the etiology and classification of peritonitis20. Explain the pathophysiology of secondary peritonitis21. Discuss the complication of peritonitis22. Explain the signs and symptoms of primary and secondary peritonitis23. Appraise the step takens to diagnose secondary peritonitis24. Interpret plain abdominal X-ray of the acute abdomen25. Discuss the supportive and definitive treatments of secondary peritonitis

ILEUS

26. Describe the definition and classification of ileus27. Compare and contrast between mechanical intestinal obstruction against adynamic ileus28. Discuss the etiology of intestinal obstruction in relation with different age groups.29. Explain the pathophysiology of intestinal obstruction30. Discuss the complications of intestinal obstruction, including : Fluid & electrolyte

imbalance, strangulation, perforated bowel, peritonitis and sepsis

31. Describe the signs and symptoms of intestinal obstruction with its complications

32. Appraise the steps taken to diagnose intestinal obstruction, including : history, physicalexamination, laboratory examinations, imaging : Plain and Erect abdominal X-ray, ErectChest X-ray.

33. Discuss the management of intestinal obstruction, including :34. Initial fluid resuscitation and supportive measures, i.e. Oxygen theraphy, decompression,

urethral catheterization, operative treatment

HERNIA35. Recognize the definition of abdominal hernia.36. Recognize the history of hernia surgery37. Recall the incidence of abdominal hernia.

38. Recognize the classification and types of abdominal hernias.


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CASE VI Page 6

39. Describe the abdominal wall anatomy, in conjunction with the pathogenesis of abdominalhernias.

40. Discuss the etiology and risk factors of inguinal hernia41. Discuss clinical manifestions, diagnosis, and treatment of inguinal hernias.42. Discuss the differential diagnosis of inguinal hernia, both in male and female

43. Compare and contrast between direct and indirect inguinal hernias44. Compare and contrast between inguinal and femoral hernia45. Explain the pathophysiology of complications of hernia, including : incarceration,

strangulation, perforated bowel, and peritonitis

46. Distinguish the clinical signs and symptoms between incarcerated and strangulated hernia47. Describe various pathological conditions related to the complications of hernia, including

Richter hernia, Littre hernia, sliding hernia, Pantaloon hernia and reduction en masse

48. Discuss the surgical treatment options of inguinal and femoral hernias, including classicopen hernia repairs, tension free hernia repairs, and laparoscopic hernia repairs

49. Explain factors that determines the prognosis of inguinal hernia50. Describe 9 other types of hernia, including : Femoral hernia, Ventral hernia, Umbilical

hernia, Obturator hernia, Perineal hernia, Spighelian hernia, Paraumbilical hernia,Epigastric hernia, Lumbar hernias

Kasus 6a Appendisitis April 2016

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