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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