Appendicitis
You are the general surgery CT1 asked to see a 19-year old man who complains of 3-day history of abdominal pain and anorexia. It was initially central but has now become localised to the right iliac fossa. He is tachycardic and has a temperature of 38.4. How would you proceed?
Example answer introduction
I suspect that this gentleman may have acute appendicitis. I would take a focused history, perform a focused examination and request the relevant investigations depending on my clinical suspicions. I would then initiate treatment and escalate to my registrar for senior review.
Initial Assessment and Simultaneous Resuscitation
On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.
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Airway
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Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns give high flow oxygen
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Circulation
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Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic
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IV access - large bore and bloods including CRP
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Give fluid challenge of 250ml crystalloid solution if evidence of shock
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If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol
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Disability - GCS, pupillary response, blood sugar, temperature
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Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!
During this acute phase state remember to provide constant reassessment
During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, Amylase, blood glucose, clotting studies, Group and Save and blood and urine cultures if spiking a temperature.
Focused history
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Allergies
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Medications
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Past medical history – Trauma, known gallstones, previous abdominal surgery, smoking, alcohol
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Last meal
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Events leading up to this point - nature of pain, nausea and vomiting, diarrhoea, constipation, weight loss, PR bleeding
Abdominal examination
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Inspect – distention, surgical/traumatic scars, discolouration, hernia
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Auscultate – diminished or absent bowel sounds
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Palpate – Tenderness, guarding at McBurney’s point, rebound tenderness, Rovsing’s sign, peritonism
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Percussion – Resonant
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Digital rectal examination – I would ask for a chaperone –melena, masses, external genitalia
Example questions to progress the station
Q1 What further investigations might you order and is there a score you know for suspected appendicitis?
I would then request the following investigations and score him on the Alvarado (MANTRELS) score.
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Urine dip – looking for blood, leukocytes, nitrites, glucose, ketones
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Ultrasound abdomen – look for evidence of appendicitis
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Abdominal x-ray – Evidence of bowel obstruction
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Erect chest x-ray – Air under diaphragm signifying perforated viscus.
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Depending on my findings he may require a CT abdomen and pelvis but I would discuss this with the registrar first.
Q2 He is tender in the right iliac fossa and Rovsing’s sign positive. He is not peritonitic. The bloods have returned showing WCC18 and CRP 120. Urine dip is negative and both x-rays appear normal to you. The ultrasound scan confirms appendicitis. What would be your further management?
Initial management
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IV antibiotics according to local protocol
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Analgesia according to the WHO pain ladder
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IV crystalloids to maintain urine output of 0.5ml/kg/hr
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Keep nil-by-mouth
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Inform the Surgical Registrar to review the patient urgently
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Prep for theatre – he will need an appendicectomy. I would consent if able.
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VTE Prophylaxis
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Keep patient and any relatives informed
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Document, document, document!!!
