alenka
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A 22-year-old woman of Polynesian descent is taken to the emergency department because of severe abdominal pain. The pain, which began about 3 hours earlier, is periumbilical. She vomited shortly after the pain started, but the nausea mostly subsided by the time she arrived at the hospital. On physical examination, she appears acutely ill and is perspiring. Her temperature is 38.1 C (100.6 F), blood pressure is 110/80 mm Hg, pulse is 110/min and regular and respirations are 22/min. The chest is clear to auscultation. On abdominal examination, there is tenderness in the right lower quadrant; this pain is also elicited when pressure is applied to the nontender left lower quadrant. The remainder of the physical examination is unremarkable. A stat complete blood count demonstrates an erythrocyte count of 4.3 million/mm3, a leukocyte count of 22,000/mm3 with 60% segmented neutrophils and 20% band forms, and a platelet count of 300,000/mm3. Which of the following is the most appropriate next step in management?
A. Barium enema
B. CT scan of abdomen
C. Esophagogastroduodenoscopy
D. Laparotomy
E. Ultrasound of abdomen and pelvis
it's a tricky one...
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| nisha
lil monkey
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answer D....MUST GO IN AND REMOVE THIS APPENDIX NOW, note this pt. is exhibiting the Rovsign sign: palpation of left iliac qud producing pain in Rt lower quad (occurs do to displacement of colonic gas, and small bowel coils impinge on the inflamed appendix)
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| nisha
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oops that was supposed to be "Rovsing"..I guess after final yr med school, i forgot how to spell 
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| drkpp
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b. ct scan of abdomen
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| drkpp
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B
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| alenka
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the answer was D.
but i still think-isn't the CT scan a gold standard for appendicitis?
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| drkpp
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i too think so cause to me it appears as acute appendicitis without perforation as no guarding or rigidity nor rebound tenderness. also for ruling out ectopic or other causes of abdominal pain...
and if no perforation no surgery. only antibiotics. 95% cases resolve with antibiotics.
surgery only if perforation or a appendicular mass.
but this protocol was in india. or atleast as far as i remember from my final year of med school.... god knows what they follow in U.S
nisha any specific reasons???
Edited by drkpp on 10/05/05 - 08:52 PM
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| nisha
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this case is a very clear cut appendicitis...periumbilical pain, somatic shifting of pain, rovsing sign and neutrophilia........if we wait, it could rupture..remember UW guys....any "itis" in the abdomen has to b managed conservatively except appendicitis..so do exp lap
Now, if this would not have been such a clear cut case we could do like kaplan says and perfor ultrasound (preferred cause cheaper) or CT both will confirm our suspicion
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| alenka
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thanks a lot,nisha.
while writing this it "hit" me!
if they give BOTH ct scan and ultrasound in the answers-probably none of them is correct-otherwise they would have given just one.
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| drkpp
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 thanx
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| chemamr
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i agree with Nisha. I donīt find which is the "tricky". Itīs D, appendicitis.
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| chemamr
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appendicitis is a CLINICAL diagnosis. CT or US are used in a very rare and doubtful cases.
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| alenka
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well,chemamr,it's great that not for everybody this question was tricky.
for me-it was.turned out-not only for me.
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| winai
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Hi , me from Thailand
just wanna add that " Appendicitis no mattter rupture or not, laparotomy everycase.. ( if HX and Physical exam confirm ) . Antibiotics prophylaxis patients 40 % ultimately return with rupture. So, as the Shwartz's Textbook of Surgery says..... HX and PE most reliable. Just go for appendectomy .
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| ruhighazi
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Hello
When there is no or little uncertainty for the Dx of appendicitis,is CT needed?
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| phuluong2k
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CT is applied for uncertain case, if no uncertainty CT is not needed
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| ruhighazi
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u are right!
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| exam
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A stat complete blood count demonstrates an erythrocyte count of 4.3 million/mm3, a leukocyte count of 22,000/mm3 with 60% segmented neutrophils and 20% band forms, and a platelet count of 300,000/mm3
Could you please explain this part of case ?and which i/v fluid and how much
Thanks
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| goldglory
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yes the answer is D.
when the diagnosis can be made by physical signs,why waste time further evaluating it.the best thing to do to save the pt is emergency laparotomy.
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| motivated2
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100% agree w/ chemamr & goldglory!
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