Turki Ali Ahmed, a 37-year old Saudi male, presented to the emergency room with sharp right lower quadrant pain for two days. On examination, he had tenderness in the right lower quadrant with rebound and other signs positive for acute appendicitis. Laboratory tests showed elevated white blood cell count. The differential diagnosis included appendicitis, testicular torsion, urinary tract infection, kidney stones, and inflammatory bowel disease. Given the clinical findings, appendicitis was considered provisional. The patient was admitted for IV fluids, NPO status, and pre-op management. He then underwent an open appendectomy and was started on IV antibiotics and pain medications post-surgery.

1. Case Presentation

2. Turki Ali Ahmed is a 37 y/o Saudi male
Presented to the ER with Right Iliac Fossa pain for 2 days

3. History of presenting illness:
 37 year old Saudi male, presented to ER complaining of Right iliac fossa pain for
2 days, pain is sharp stabbing in nature, increased in severity today, aggravated
by movement and not relieved by anything, pain doesn’t radiate, pain is 10/10 on
Wong Baker scale
Associated symptoms:
 Nausea, vomiting and loss of appetite.
 No fever

4. Past medical history:
 No DM, HTN, Asthma or kidney failure
 Past medication: non
Past Surgical history:
 Left hand fracture and cut due to RTA 3 years ago
Blood transfusion history: non
Allergies: NO known allergies
Family history:
 His father has DM and HTN
Social history:
 lives in a villa in Riyadh, good socio-economic status, traveled to Dubai 1 year
ago, no history of smoking or alcohol consumption or drug abuse

5. Systemic review: Unremarkable
General: NO weight loss, night sweats, fever
HEENT: NO headache, NO change in vision, hearing or smell and NO difficulty in
swallowing
CVS: NO palpitation or chest pain
Respiratory: NO shortness of breath or cough
Gastroenterology: NO constipation or diarrhea, NO bleeding or change in color
Genitourinary: NO blood or foul smell or burning sensation
Dermatological: NO itching or redness
Musculoskeletal: NO pain/swelling/stiffness in muscle/joints/back
CNS: NO numbness or weakness
Endocrine: NO hot or cold intolerance, NO loss or gain of weight

6. Physical examination
 General appearance:
looks ill, lying uncomfortably, grasping on clothes, afebrile
 Vital signs:
 Temp: 37.0 ᵒC
 PR: 70 beats per minute
 BP: 146/72 mmHg
 RR: 18 breaths per minute
 O2: 98%

7. Hands
 Hands were warm and dry
 No clubbing, koilonychia or leukonychia
 No peripheral cyanosis
 No palmar erythema
 Normal sensation
Head and Neck
 No swelling observed
 No conjunctival pallor
 No jaundice
 No central cyanosis
 No mouth ulcers
Legs
 No pitting edema
 No swelling
 No redness
 Normal sensation

8. Abdominal Examination:
Abdomen was soft and lax, no organomegaly,
right iliac fossa tenderness
 Rebound tenderness positive
 Mcburney’s sign positive
 psoas sign positive
 Flank tenderness negative
 Obturator sign negative
 Dunphy's sign negative
 Rovsing's sign negative
Rectal examination may reveal localised tenderness
as the only sign of an inflamed retrocaecal or pelvic
appendix

10. Chest examination:
 Symmetrical, Normal bilateral air entry,
 Vesicular breathing, no bubbling or cracking sounds
Cardiovascular:
 Normal Heart sound S1, S2 (NO added sound)
 Normal capillary refill

11. Lab Tests:
1-CBC
 Elevated WBCs

12. 2- Biochemistry
3- Liver Function Test
4- Electrolytes Profile
 Findings were normal

13. Differential diagnosis

14. 1- provisional diagnosis
Acute appendicitis:
 History
 physical
 Alvarado score:
Score <4: No imaging required (Appendicitis unlikely)
Score 4-6: CT Abdomen
Score >6: Surgical Consultation
 Patient Score >6
Alvarado score
RIF tenderness +2
Increased WBC +2
Pain that migrates to RIF +1
Rebound tenderness +1
Anorexia +1
Nausea/Vomiting +1
Fever +1
WCC- left shift +1

15. Differential diagnosis:
Testicular torsion:
 Swelling of the scrotum
 Painful urination
 Fever
Urinary tract infection
 A burning feeling when urinating
 Cloudy, dark, bloody, or strange-smelling urine
 Fever or chills
 Urine microscopy and culture confirm presence of bacteria.
Right side ureteric colic
 Hematuria
 Referred pain to the scrotum
Chron’s disease
 Age group
 Fever
 Diarrhea
 History

16. Management:
Admit the patient
1- Stabilize
IVF (D5 1L) + (NS 120ml/h)
2-Monitor
 NPO
 Pre op
 Anesthesia [omeprazole 40mg IV]
 Antibiotics [Cefuroxime 1.5g IV on call to OR]
3-surgery
open appendectomy
4- post surgery
 Antibiotics:
cefuroxime750mg BID IV,
flagyl 500mg BID IV
 Paracetamol
1g Q6hrs IV