A 74-year-old man presented with abdominal pain, nausea, vomiting and fever for 2 days. He has a history of hypertension and ischemic heart disease treated with medications. On examination, he had tenderness in the right lower quadrant. Tests showed elevated white blood cell count and ultrasound revealed inflamed appendix with fluid in the right lower quadrant. The provisional diagnosis was acute appendicitis requiring an emergency open appendicectomy.

1. Ischemic Heart Disease with
Hypertension
Speaker : Dr. Fatema Khanbhaiwala
3rd year M.D. Anaesthesiology Resident
Narendra Modi Medical College and Sheth L.G. Hospital

2. Case Presentation
 Patient Details
 Name - Nanjibhai
 Age - 74
 Sex – Male
 Weight – 80 kg
 Height – 168cm
 BMI – 28.34
 Residence – Gujarat
 Religion – Hindu
 Occupation – Autodriver
 Socio economical Class – Lower

3. Chief Complaint
 A 74 years old male Patient came to L.G. Hospital on 20th February 2023 with chief
complaints of
 Abdominal pain – 2 days
 Nausea – 2 days
 Vomiting – 1 day
 Fever – 1 day

4. ODP
 Patient was relatively asymptomatic before 2 days.
 Then he developed abdominal pain which was sudden in onset, started at
periumbilical region and radiated towards right iliac fossa and increased in
intensity while walking.
 Pain was associated with nausea since 2 days and vomiting since 1 day, 2-3
episodes of vomiting since 1 day which was yellow in colour, non projectile,
containing food particles, vomitus didn’t contain blood or coffee coloured content
and not associated with headache or food intake and low grade fever.

5.  Patient is a known case of Hypertension and Ischemic heart disease since 7
months and he is on following treatment.
 Patient came with treatment card and drugs.
 T. Aspirin (150) [0-1-0]
 T. Clopidogrel (75) [0-1-0]
 T. Atorvastatin (40) [0-0-1]
 T. metoprolol (25) [1-0-1]
 T. NTG (2.6) [1-0-1]

6. Past History
 Patient had history of chest pain which was sudden in onset and of squeezing type,
radiating towards left arm and left jaw,
 Associated with palpitations and shortness of breath, perspiration
 Not relieved by rest
 Not associated - giddiness, dizziness, loss of consciousness, muscle weakness in limbs,
decreased urine output, oedema over bilateral lower limbs, was not associated with
cough with expectoration, pink frothy sputum, cold periphery,
 Hospitalized for the same and some investigations were done.
 At that time he was diagnosed with Acute Coronary Syndrome for which he
underwent Coronary Angiography.
 Which was suggestive of single vessel disease with 80% stenosis in LAD and it was
treated medically.

7.  No similar complaints in past.
 No history of other systemic illness like DM, bronchial asthma, T.B. , jaundice.
 No history of trauma, blood transfusion.
 Patient had no surgical history in past.

8. Family History
 Patient’s father was having hypertension and ischemic heart disease.

9. Drug / Allergy History
 No allergic history

10. Personal History
 On mixed vegetarian diet with decreased appetite
 unaltered bowel and bladder habit with adequate sleep.
 Chronic tobacco chewer since 30 years.
 No other addictions like smoking or alcohol at present.

11. General Examination
 After taking consent, I have examined the patient in proper light and exposure and
in sitting position.
 Patient is conscious, oriented to time, place and person and co-operative and
following verbal command.
 Well nourished
 moderately built.
 Height -168 cm
 Weight - 80 kg
 BMI of 28.34 kg/m²

12.  Temperature – normal on touch
 Pulse – 88/min in sitting position in right radial artery, Regular rate rhythm, Normal
force, volume, tension, No radioradial or radiofemoral delay.
 BP – 136/80mmHg in right brachial artery in sitting position and auscultatory
method.
 Spo2 – 97% on room air
 Respiratory rate – 16-18 / min – abdomino thoracic type
 Breath holding time – 22 seconds
 E.T. – fair
 Patient is able to walk fast
 Climbs 2 flight of stairs
 METS score – 5-6 METS

13.  No any signs of jaundice, anemia, cyanosis, clubbing, oedema or
lymphadenopathy.
 No neck vein engorgement.
 No any skeletal or muscular deformity.

14. Airway Assessment and spine examination
 M.P. grade – 2
 Mouth opening – 3 fingers
 Neck flexion – adequate
 Neck extension – adequate
 TMD – 6.5 cm
 Teeth – all present, no artificial or loose tooth, staining present
 Spine – Normal

15. Systemic Examination
 At present, as patient is having complaints of abdominal pain and vomiting, I
would examine GIT system but as patient had complaints of chest pain and
palpitations in past and patient is on antihypertensives, antiplatelets,
anticoagulants, I would like to examine CVS first.
 I have examined patient in semi reclining position in proper light and exposure.

16. Inspection
 Normal shaped precordium
 Overlying skin normal
 Chest size and shape normal
 Apex impulse – 5th IC space, 2 cm inside midclavicular line.
 No visible pulsations, bulging or dilated veins seen
 No scars or sinuses

17. Palpation
 I would like to confirm my inspectory findings by palpation.
 Temperature – normal
 Apex beat – left 5th IC space, 2 cm inside mid clavicular line located by pulp of
index fingers
 Carotid artery pulsations are raised in right and left side
 No other palpable sound over precordium.

18. Percussion
 Dull note of left heart border is felt at left 3rd , 4th and 5th ICS 4cm, 7cm and 9cm
away from midsternal line
 Liver dullness in right 5th , 7th and 9th ICS in midclavicular, midaxillary and scapular
line respectively

19. Auscultation
 Done in supine position
 S1 S2 heard over Mitral, Tricuspid, Aortic and Pulmonary area.
 No murmur or any foreign sounds.

20. GIT
Inspection
 Abdomen – globular
 Moving regularly with respiration
 Umbilicus – centrally placed, inverted,
normal
 No venous distention
 No abdominal distention
 Back and spine normal
 No sinuses or scars
 No visible peristalsis or pulsations
 No scrotal swelling

21. palpation
 No local rise in temperature
 Tenderness in RIF at Mc burney’s
point.
 Best elicited in left lateral position.
 Localized rigidity and guarding over
RIF.
 Liver , spleen, kidney non palpable
 No lump
 No expansile impulse on cough
impulse at hernial sites.
 No renal angle tenderness.
 Both testes are in scrotum, normal
size and consistency.
 Testicular sensation present.

22. Percussion
 normal tympanic note
 Upper border of liver dullness in right 7th ICS in midclavicular line, 8 finger breadth
below costal margin in mid clavicular line & 2 finger breadth lateral to umbilicus.

23. Auscultation
 Normal peristalsis heard.
 No audible bruit.

24. R.S.
 Upper respiratory tract normal
 Shape of chest normal with bilateral equal movement.
 Normal bilateral vesicular sound present
 Abdomino thoracic breathing type
 RR – 16-18/min
 Trachea centrally placed

25. C.N.S.
 Patient is conscious, oriented and following verbal commands
 GCS -15/15.
 Sensations normal in both upper and lower limb.
 5/5 power in both upper and lower limbs.
 Bowel bladder sensations intact.

26. Probable diagnosis
 74 years old male patient, known case of hypertension and
ischemic heart disease since 7 months and on regular
treatment presented with complaints of abdominal pain,
nausea, vomiting and fever since 2 days under investigations.

27. Preoperative investigations available
 Hb- 12.1 gm/dl
 TLC – 13,400 cells/ul
 APC – 2.14 lacs
 PT/INR – 13.4/1.7
 Sr. Creatinine – 1.053 Urea – 18
 Serum electrolytes – Na+ - 134, K+ - 4.6, Cl- - 107
 Sr. bilirubin – 1.2 SGPT – 56 ALP – 110
 RBS – 110 mg/dl
 CXR – NAD
 ECG – WNL/NSR
 USG – 12 mm inflamed appendix with minimal fluid collection in RIF.

28. Provisional diagnosis
 74 years old male patient known case of hypertension and ischemic heart disease
since 7 months and on regular treatment presented with complaints of abdominal
pain, nausea, vomiting and fever since 2 days, diagnosed with acute appendicitis
from ultrasound sonography of abdomen and posted for emergency open
appendicectomy.