Episodic Notes and Analysis: Appendicitis - Lab Report Example

EPISODIC S AND ANALYSIS: APPENDICITIS Part EPISODIC S IDENTIFICATION T.S. Age: 15 years old Gender: Female Race: Black American Chief complaint: “I am having a severe pain on the right lower portion of my abdomen and the pain becomes more intense every time I move.” SUBJECTIVE At 9:30AM of September 6, 2008, a 15 year old teenage black American female presents right lower quadrant abdominal pain (8/10 in intensity and constant) in the clinic. Onset of pain started at 3AM this morning when client was awakened by an abdominal pain on the periumbilical region, 3/10 in intensity. Pepto-Bismol oral suspension was taken, 30ml at 3AM and another 30ml at 6AM. She still managed to go to school despite of abdominal pain felt but the pain grew intense, 6/10, and moved to lower part of the abdomen. No associated vomiting but positive in anorexia, nausea, and is febrile. No breakfast yesterday, lunched with half cup of rice and chicken, and half cup of rice, beef steak, vegetables and soup for dinner. No food intake since this morning but water only. Last defecation was yesterday morning with a soft stool and no tinge of blood on stool. For medical history, client completed the series of immunizations during childhood, has no allergies to certain drugs or foods and was never been admitted in the hospital for any medical problems. Last menstrual period was on August 26, 2008 and the client is not sexually active. OBJECTIVE The client is an adolescent black female with average body built, alert, and oriented. Vital signs were: BP-116/66 mmHg, T-102.0° F, PR-78 bpm, and RR-28 cpm. Shows facial grimace and guarding behavior, lips are dry, throat is clear, mucous membranes are moist, neck is supple, chest is clear, positive right lower quadrant flank tenderness to palpation in the abdomen, no mass, no inflammation, and positive in Rovsing’s sign (pain on the right lower quadrant when left lower quadrant is palpated). Client refused to be examined on the genitor-urinary portion. No rash or edema on extremities, no scars/skin lesions and no palpable mass. ASSESSMENT With the signs of abdominal pain on the right lower quadrant, positive Rovsing’s sign, guarding behavior and the rest of the subjective and objective cues gathered, this case is to consider acute appendicitis. Most common conditions that mimic the signs and symptoms of appendicitis in children are gastroenteritis (diarrhea is more profound as a sign), constipation and urinary tract infection. Other conditions considered for differential diagnosis are pelvic inflammatory disease, ovarian torsion, primary peritonitis and intestinal adhesions. PLAN Inform the family of the child about what had happened. Transfer patient to the emergency department of the hospital or refer immediately to the physician since acute appendicitis is an emergency surgical case. No pain medications shall be administered for this may mask the true pain symptoms. Back rubbing can be done to provide comfort. Laboratory tests for follow-up include CBC to ascertain signs of infection (increased WBC is expected), urinalysis to rule out urinary tract/bladder infection or kidney stone, and urine pregnancy test to rule out pregnancy. Diagnostic tests are: Abdominal X-Ray (uses invisible electromagnetic energy beams to rule out presence of an appendix stone), Ultrasound Examination (uses high frequency sound waves to create an image of intestinal organs to rule out ovarian cyst), and Computed Tomography (CT) Scans (uses a combination of x-rays and computer technology to produce cross-sectional images to show an enlarged, swollen appendix, which often presents as a target sign). Also, explain appendectomy as the immediate surgical treatment for appendicitis and NPO (nothing per orem) adherence for preparation of surgery. Pain medications (analgesics) and antibiotics (cefotetan or cefoxitin) for treatment of bacterial infection in appendicitis shall be administered as ordered. Side effects of antibiotics are loss of appetite, nausea, vomiting, diarrhea, and headache. For client and family education for home management, patient must have a light diet and limit her physical activity for a period of 2-6 weeks based on the surgical approach. The patient should be evaluated by the surgeon in the clinic to determine improvement and to detect any possible complications. Check the incision for infection and call the doctor if fever occurs or other signs of infection are noticed such as redness, swelling, pus, or pain in your lower abdomen or if the patient is not able to eat normal foods after 5 days. Part 2 - ANALYSIS Two scholarly articles about management of appendicitis in children were utilized for analysis of the case. (1) Appendicitis (July 23, 2008) written by David Hackam, an associate professor of surgery at University of Pittsburgh School of Medicine and co-director of Fetal Diagnosis and Treatment Center in Children’s Hospital of Pittsburgh, and (2) Appendicitis (August 26, 2008) is written by Dr. Scott Strahlman, a member of the American Academy of Pediatrics (AAP) and one of the authors of AAP Textbook of Pediatric Care. SUBJECTIVE The first article by Hackam presents subjective information that are similar in the original case, only that a detailed history taking of present should have been made like the patterns of pain and its description and duration starting from the time when this sign was first felt. Information about abdominal pain felt days before the highest pain symptom should have been asked also from the child. Family (parental) health history should have been considered but this was not able to do because parents were not available when the incident happened. Strahlman’s article points out a good linkage on the historical pain symptoms of appendicitis manifested by the client in the case and that is having been awakened by an intense pain during sleep. Though history was gathered on the case, this article points out that detailed description of the pain felt by the child should have been considered, like if it is dull and steady on what particular region and for how long. OBJECTIVE According to Hackam, part of physical examination in diagnosing a client with appendicitis is to observe involuntary guarding where the abdominal muscles may actually contract involuntarily after being pressed. Rovsing’s sign (pain felt on RLQ when LLQ is pressed) was mentioned in this article as one of the eminent signifying symptom of appendicitis and this has been observed during the actual physical examination of the client. More significant points for consideration were found out on the article of Strahlman during the analysis. One that should have been included is the assessment for peritoneal signs such as pain on walking or coughing. If the patient can jump up on the examining table, then the patient does not usually have appendicitis. Other signs that should have been part of the physical assessment according to Strahlman are the pain in the right lower quadrant may be accentuated when the inflamed appendix is located retrocecally by (1) placing the patient in the left decubitus position and extending the right leg at the hip, thereby placing tension on the right psoas muscle, the origins of which underlie the appendix (psoas sign); and (2) placing the patient supine and internally rotating the flexed right hip, thereby extending the right internal obturator muscle, the origins of which also underlie the appendix (obturator sign). Bowel sounds (whether diminished of hyperactive) was also not assessed. ASSESSMENT All of the differential diagnosis mimicking signs and symptoms of appendicitis on the first article were also mentioned on the original case and these are urinary tract infection, constipation, ovarian torsion and gastroenteritis. While on the second article, part of Strahlman’s differential diagnosis that should have been considered on the case are diabetic ketoacidosis, right lower lobe pneumonia, ruptured ectopic pregnancy, dysmenorrhea, mittelschmerz, ruptured corpus luteum cyst, intussusception, meckel diverticulitis, necrotizing enterocolitis and in rare cases are henoch-schönlein purpura, hemolytic-uremic syndrome rocky mountain spotted fever. PLAN Plan of care and treatment in both articles are almost the same to those mentioned on the case as to the laboratory, diagnostic tests and surgical treatment for appendicitis but the second article says that once the diagnosis is made intravenous hydration is started – this information should have been included as part of the plan. Acetaminophen given by rectum is administered to control the client’s fever. Broad spectrum of antibiotics mentioned on the article should have been included for medications and these are ampicillin, gentamycin, and clindamycin or cephalosporin. Hackam mentioned in his article that in rare cases scar tissue will form within the abdomen any time that surgery is performed there, and over time, this could potentially cause intestinal blockage and this information should have been included on the client/family teachings. Also to add that any patient who has undergone surgery and subsequently develops signs of intestinal blockage – such as abdominal pain, green vomiting, or failure to keep any liquid or solid down – should receive prompt medical attention. Works Cited: Department of Health, NSW (January 27, 2005). Children and Infants with Acute Abdominal Pain – Acute Management. Article available at: < http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_384.pdf > Hackam, D. (July 23, 2008). Appendicitis. Knol Beta, A unit of Knowledge. Available at: < http://knol.google.com/k/david-hackam/appendicitis/RNKGbbtd/Z1o0Yg# > Strahlman, S.R. (August 26, 2008). Appendicitis. American Academy of Pediatrics’ Textbook of Pediatric Care. Link to the article is available at: Read More