For Examiner Only



For Examiner Only

Case Appendicitis

Author: Lynne McCollough, MD Reviewer: Douglas Char, MD Approved: 2/13/06

ORAL CASE SUMMARY

CONTENT AREA

Gastrointestinal

SYNOPSIS OF CASE

Young man with no past medical history presents with an uncomplicated story of lower quadrant abdominal pain consistent with acute appendicitis

SYNOPSIS OF HISTORY

Less than 24 hour history of right side abdominal pain, nausea, vomiting, anorexia and subjective fever, no GU symptoms, no history of chronic illness, travel or ill contacts

SYNOPSIS OF PHYSICAL

Dry mucous membranes, mild tachycardia but stable vitals. Point tenderness on palpation at McBurney’s point. Mild voluntary guarding but no rebound. He has a normal GU exam

CRITICAL ACTIONS

1. Consult surgeon for diagnosis of appendicitis

2. Administer IVF for dehydration

3. Administer anti-emetics for nausea and vomiting

4. Administer pain medication for patient’s comfort

5. Obtain confirmatory imaging study

SCORING GUIDELINES

(Critical Action No.)

1. Call for surgery consult early, if candidate waits until all the other labs are back have patient decompensate – rupture the appendix (score down for long delays)

2. If no resuscitations with IV fluid started score down and have the patient vomit more

3. If provider fails to give mediation for nausea/vomiting increase symptom frequency and severity

4. If provider fails to give pain medication (enough to take off edge but not enough to alter examination) take off points

5. Confirmatory imaging study will probably required in this day and age but if provider is persistent and gets surgery to the bedside score up a few points.

FOR EXAMINER ONLY

For Examiner Only

PLAY OF CASE GUIDELINES

(Critical Action No.)

Given lack of other history, appendicitis should be on top of the differential diagnosis and candidate shouldn’t waste lots of time working up a broad differential before consulting surgery. While ancillary test such as UA for stone, KUB, ultrasound or CT abd might be requested, candidate should ask that surgery come and see the patient not just order labs to delay their evaluation.

If candidate is able to get surgery to come early to the bedside patients exam should be classic enough to warrant exploratory laparotomy without further imaging.

FOR EXAMINER ONLY

For Examiner Only

Critical Actions

1. Consult surgeon for diagnosis of appendicitis

This critical action is met by the candidate

Cueing Guideline: patient or nurse to ask “what do you think is wrong with me [him}?”

2. Intravenous fluid resuscitation

This critical action is met by the candidate

Cueing Guideline: patient to complain of thirst

3. Anti-emetics

This critical action is met by the candidate

Cueing Guideline: patient to complain repeatedly of nausea, nurse to complain of vomiting

4. Judicious pain relief

This critical action is met by the candidate

Cueing Guideline: patient to continue to complain of pain until meds are given

5.

This critical action is met by the candidate

Cueing Guideline:

For Examiner Only

History Data Panel

Onset of Symptoms: middle of the night.

Description of Complaint: Awoke with abdominal pain mildly ill appearing. Diffuse. Crampy. Non-radiating. Associated with nausea, vomiting, anorexia, subjective temperature, Ø diarrhea, one loose stool today, no blood or mucus Ø urinary symptoms Ø penile discharge Ø ill contacts Ø travel Ø history of same symptoms Ø pulmonary symptoms

Past Medical History

Surgical: none

Medical: asthma

Injuries: none

Allergies: none

Medications - albuterol MDI prn

Habits

Smoking: none

Drugs: occasional marijuana

Alcohol: social

Family Medical History

Father: high blood pressure

Mother: none

Siblings: none

Social History

Married: no

Children: no

Employed: software engineer

Education: college

Not sexually active, Ø history of STD’s

For Examiner Only

Physical Data Panel

Patient Name: Michael Pearson

General Appearance: well developed, well nourished young man in mild distress, lying in fetal position on side

Vital Signs:

BP : 112/65

P : 110

R : 18

T : 38.3° C

Head: NCAT

Eyes: PERRL, no conjunctival injection, anicteric

Ears: normal

Mouth: dry mucous membranes

Neck: supple

Skin: warm, dry, no rash, but slightly flushed

Chest: clear to auscultation bilaterally

Heart: tachycardic, regular, without murmurs, gallops or rubs

Abdomen: diffuse tenderness to palpation, (+) guarding (+) psoas (-) obturator (-) CVAT (+) McBurney’s (-) Murphy’s

Extremities: well perfused, 2+ pulses,

Rectal: normal prostate, non-tender, heme (-)

Genitourinary: bilaterally descended testes, uncircumsized penis, no discharge or lesions, no hernia

Neurological: normal

Mental Status: alert and oriented to person, place, time

For Examiner Only

Lab Data Panel

|Stimulus #2 - Hematology |Stimulus #5 – Abdominal Series-non-specific bowel gas pattern, no |

|Complete Blood Count |air/fluid levels |

|WBC 13/mm3 | |

|Hgb 14.1g/dL | |

|Hct 43.2% | |

|Platelets 315 /mm3 |VERBAL REPORTS |

|Differential | |

|Segs 87% |Ultrasound of the appendix: appendicitis |

|Bands 3% | |

|Lymphs 8% |CT scan of abdomen/pelvis: stranding in the RLQ and a fluid filled |

|Monos 3% |appendix consistent with appendicitis |

|Eos 1% | |

| | |

| | |

|Stimulus #3 - Chem-7 | |

|Na+ 142 mEq/L | |

|K+ 3.2 mEq/L | |

|CO2 18 mEq/L | |

|Cl- 114 mEq/L | |

| | |

|Glucose 98 mg/dL | |

|BUN 21 mg/dL | |

|Creatinine 1.1 mg/dL | |

| | |

| | |

| | |

|Stimulus #4 - Urinalysis | |

| | |

|Color yellow | |

|Sp gravity 1.018 | |

|Glucose neg | |

|Protein neg | |

|Ketone 1+ | |

|Leuk. Est. neg | |

|Nitrite neg | |

|WBC 3 | |

|RBC 2 | |

| | |

For Examiner Only

Stimulus Inventory

# 1 Emergency Admitting Form

# 2 Hematology

# 3 Chemistry-7

# 4 Urinalysis

# 5 Plain films of the abdomen

# 6 Ultrasound of RLQ

# 7 CT scan abd/pelvis

FOR EXAMINER ONLY

Stimulus #1

ABEM General Hospital

Emergency Admitting Form

Name Michael Pearson :

Age 27 :

Sex Male :

Method of Transportation Private Auto :

Person giving information Patient :

Presenting complaint abdominal pain :

Background: Mr. Pearson was in his usual state of health until yesterday when he experienced gradual onset of abdominal pain, nausea and vomiting

Vital Signs

BP : 110/65

P : 108

R : 20

T : 38.2° C

Stimulus #2 – Hematology

Complete Blood Count

WBC 13/mm3

Hgb 14.1g/dL

Hct 43.2%

Platelets 315 /mm3

Differential

Segs 87%

Bands 3%

Lymphs 8%

Monos 3%

Eos 1%

Stimulus #3 - Chem-7

Na+ 142 mEq/L

K+ 3.2 mEq/L

CO2 18 mEq/L

Cl- 114 mEq/L

Glucose 98 mg/dL

BUN 21 mg/dL

Creatinine 1.1 mg/dL

Stimulus #4 - Urinalysis

Color yellow

Sp gravity 1.018

Glucose neg

Protein neg

Ketone 1+

Leuk. Est. neg

Nitrite neg

WBC 3

RBC 2

Stiumulus #5 Plain films abdomen

Stimulus #6 Ultrasound Abdomen

[pic]

Stimulus #7 CT Abd & Pelvis

[pic]

[pic]

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