Surgery OSCE Quiz 5

http://jacknaimsnotes.blogspot.com/2010/02/surgery-osce-quiz-5.html

A 67 Years Old Malay Lady with past medical history of pulmonary tuberculosis and has

completed treatment currently presented with fever for 3/7. It is a high grade fever associated

with chills but no rigor. The fever is temporarily relieved by tab. Paracetamol. There is no

pleuritic chest pain, haemoptysis, shortness of breath, night sweat and no symptoms of urinary

tract infection.

Two days later, she develops Right iliac fossa pain that brought her to hospital. It is pricking in

nature, continuous, increase in frequency when coughing and not radiate to any part of body. It

is also associated with anorexia and nausea.

After a thorough examination, she was prep for surgery and organ x was removed.

Below is the picture of organ X

Questions

1) What is organ X, and how do you identify it?

2) Name the blood supply to organ X

3) What is your differential diagnosis?

4) What is your provisional diagnosis?

5) What clinical sign to elicit in supporting your provisional diagnosis?

6) What usually caused organ X to be removed?

7) What is the complication that can develop in this patient?

8) How do you manage the patient from the first time she presented to you until

discharged.

Answer

1) Vermiform Appendix

It is a blind muscular tube with mucosal, submucosal, muscular and serosal layer.

2) Appendicular artery from branch of ileocolic artery

3) Differential diagnosis

a) Perforated appendicitis

b) Ruptured TB intestine

c) Mesenteric adenitis

d) Urinary tract infection

e) Inflammatory bowel disease

f) Infective GIT condition

g) Meckel’s diverticulitis

h) Renal or ureteric calculi

i) Ovarian pathology (twisted ovary, ruptured ovarian follicle)

j) Caecal ca

k) Perforated bowel

4) Provisional diagnosis is perforated appendicitis

5) Clinical sign

a) Pointing sign (ask patient to show site of pain initially start and where it migrates

b) Rovsing’s sign (deep palpation of left iliac fossa cause pain to right iliac fossa)

c) Psoas sign. (Patient lay down with right hip flexed to relieve pain.

d) Obturator or Zachary Cope sign (flexing and internal rotate of hip cause pain)

6) Cause of organ x need to be removed

a) Mostly due to obstruction that may be caused by

i. Faecolith

ii. Seeds

iii. Worms (Oxycuris vermicularis)

b) Invasion of appendix wall

i. Parasites (amoeba, schistosomas)

c) Lymphoid hyperplasia

7) Complication

a) Local peritonitis with formation of appendicular mass

b) Abscess formation

i. Subphrenic

ii. Subhepatic

iii. Interloop

iv. Paracolic gutter

v. Wound

vi. Pelvic

c) Gangrene of Appendic

d) General peritonitis.

8) Management

a) Resuscitation and acute management of the patient

i. Monitor the vital sign

ii. Get an IV access

iii. Keep nil by mouth

iv. Fluid therapy 3 pints (2 pints normal saline and 1 pints dextrose 5%)

v. Urinary catheter to observe fluid output (normally 0.5 cc/kg/ hour in well

hydrated adult)

vi. Pain killer, IM pethidine 50 mg stat

vii. IV Pentaprazole

viii. Thorough fever work up (blood culture and sensitivity, urine FEME, urine culture

and sensitivity)

ix. Empirical antibiotic covering enteric bacteria.

b) Establishing diagnosis

i. Mostly, diagnosis is made by clinical (history and examination) can use Alvarado

scoring for appendicitis. Therefore, other investigation is not needed.

ii. Full blood count may show Leukocytosis

iii. ESR may elevate.

iv. Ultrasound and contrast enhanced CT scan (if diagnosis is uncertain and if there

is high possibility of other causes than appendicitis is anticipated

c) Definitive treatment is Appendicectomy

i. Pre Op

- Stabilize the patient

- History taking to identify high risk patient.

- Keep nil by mouth

- Blood investigation (FBC, GSH, RFT, LFT)

ii. Intra Op

- Surgery under general anesthesia

- Cover un necessary part to avoid hypothermia

- Adequate skin prep

- Use gridiron or lanz incision

- Identify the appendix by locating the taenia coli.

- Take swab from perforated appendix for culture and sensitivity

- Peritoneal irrigation with 2 liters warm normal saline after removal of

perforated appendicitis and closure of removal site

- Drainage is not compulsory in view of complete peritoneal irrigation.

iii. Post Op

- Monitor the patient in the recovery area

- Keep nil by mouth

- Transfer the patient to ward once stable.

- Analgesic (IV Tramadol)

- IV Pantaprazole

- Continue antibiotic to cover gram negative and anaerob (Ciprobay and

flagyl) because the appendix has perforated.

- Daily checking of surgical wound and dressing if required.

- Allow discharge with tablet antibiotic and pain killer once patient

recovery is satisfactory.

Reference

1. Alastar M. Thompson, “General Surgery Anatomy And Examination”, Churchill Livingston, 2002

2. Danny O’ Jacobs, “First Exposure General Surgery”, Mc Graw Hill Company, 2007 3. Norman S. Williams, Christopher J.K. Bulstrode & R. Ronan O’Connel, “Bailey & Love’s Short Practice

of Surgery 25th edition”, Edward Arnold Publisher ltd, 2008 4. World Health Organization, “Surgical Care at the District Hospital”, WHO, 2003