Acute Appendicitis

Chapter 39 Acute Appendicitis

Clinical Case Problem 1 A 29-Year-Old Woman with Nausea, Vomiting, and Central Abdominal Pain

A 29-year-old woman comes to your office with a 1-day history of nausea, mild vomiting, and vague central abdominal pain. The pain has begun to move down and to the right. She also describes mild dysuria. Anorexia began 24 hours ago, and the patient has “felt warm.” Her last menstrual period was 2 weeks ago.

Her past health has been excellent. She has no drug allergies and is not taking any medications. On physical examination, she appears ill. Her temperature is 38.1°C. She has tenderness in both the right lower quadrant and the left lower quadrant, but tenderness is greatest in the right lower quadrant. Rebound tenderness is present. The rectal examination discloses tenderness on the right side. There is no costovertebral angle tenderness.

Select the best answer to the following questions

1. What is the most likely diagnosis in this patient?

a. pelvic inflammatory disease (PID)

b. ovarian torsion

c. acute appendicitis

d. acute cholecystitis

e. acute pyelonephritis

2. At this time, what would be the most reasonable course of action?

a. advise the patient to go home and return for follow-up in 24 hours

b. hospitalize the patient for observation, evaluation, and possible operation

c. begin outpatient oral antibiotic therapy and see the patient in 48 hours

d. advise the patient to go home and call you if no improvement occurs within the next 72 hours

e. none of the above

3. Which of the following laboratory markers would be most helpful in supporting the diagnosis?

b. white blood cell (WBC) count

c. C-reactive protein

e. pregnancy test

4. A consultant sees your patient and makes an appropriate suggestion. Which of the following is the suggestion likely to be?

a. perform an abdominal laparoscopy or laparotomy

b. begin intensive triple-drug intravenous antibiotics

c. continue the period of observation

d. perform further diagnostic tests

e. order another consult

5. Which of the following is not a clear complication of the original condition and definitive therapy?

a. wound infection

b. intra-abdominal abscess formation

c. portal pylephlebitis

d. bowel obstruction

6. In which of the following groups are the signs and symptoms of the condition described likely not to be classic?

b. young adult men

7. In which of the following age-groups is the diagnosis of the condition described here most likely to be confused with another serious intra-abdominal inflammatory condition?

b. young children

c. young adult men

d. young adult women

e. elderly men and women

8. Regarding the pathophysiology of the described condition, which of the following is not a usual component of the pathologic process?

a. obstruction of the organ, accounting for early symptoms and signs

b. hypoperistalsis, leading to abdominal cramping

c. rapid invasion of the wall of the organ by bacteria, leading to inflammation

d. spreading of the inflammation to involve the whole wall of the organ

e. gangrene and perforation of the organ

9. Mortality is highest in which of the following groups?

b. young adults with rupture of the organ

c. children with rupture of the organ

d. elderly with rupture of the organ

e. pregnant women

10. All except which of the following statements about the management of this condition when rupture occurs are true?

a. more aggressive fluid resuscitation is usually necessary

b. intravenous antibiotics should be given for 7 to 10 days or until the patient is afebrile

c. insertion of a percutaneous drain before surgery is recommended

d. open laparotomy or laparoscopy can be performed

e. expect a prolonged recovery with longer duration of fever and elevated WBC count

11. The test with the highest sensitivity in diagnosis of this condition is

a. ultrasonography

b. barium enema

c. abdominal radiograph

d. computed tomography (CT) with intravenous and oral administration of contrast agents

e. nuclear medicine WBC-labeled scan

Clinical Case Problem 2: A 3-Year-Old Boy with 4 Days of Abdominal Pain

A 3-year-old boy is brought into your office by his parents after 4 days of abdominal pain. His parents state that it appeared their son had some pain in his abdomen, and they assumed he had a simple “stomach virus” with some associated vomiting and malaise. They decided to bring him to the office because he was not completely better. They noted he “felt warm” during the past few days and had not been eating much. Per the parents, the pain seems to be improved today but he is still not himself. On examination, the temperature is 38°C and the pulse is 105 beats/minute. The boy appears ill but is not lethargic or in any distress. Abdominal examination reveals tenderness in the right lower quadrant with deep palpation. The abdomen is otherwise soft, and there is no guarding or rebound tenderness. You suspect the patient has appendicitis.

12. You call the local radiologist and she is able to see your patient right now. What imaging modality is most appropriate in this setting to confirm your suspicions?

a. CT scan with rectal contrast material

b. CT scan with oral contrast material

c. CT without contrast material

d. ultrasonography

e. magnetic resonance imaging

13. All except which of the following may be positive physical examination signs in acute appendicitis?

a. Rovsing sign

b. pain at McBurney point

c. McMurphy sign

e. obturator sign

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Tags: Swansons Family Medicine Review

Oct 1, 2016 | Posted by admin in GENERAL SURGERY | Comments Off

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