A 28-year-old female presented with 4 days of abdominal pain that started around the umbilical area and shifted to the right lower quadrant, accompanied by fever and diarrhea. On examination, she had tenderness and rebound tenderness in the right lower quadrant, along with other signs positive for appendicitis. Laboratory tests showed elevated white blood cell count with neutrophilia. Based on her history, presentation and test results, she was diagnosed with acute appendicitis.

1. History of
Patient
• Sex----Female
• Age----28yrs
• Marital status------ married
4 days ago she felt light to mild
abdominal pain around the
umbilical. the pain gradually
shifted to right lower quadrant
of the abdomen. At the 4th
day
she felt abdominal pain
becoem sever with fever and
diarrhea for 2 times. So she
went to see the doctor and
was admitted in the hospital.

2. Physical Examination
• Conscious state
• Temp. 38.5 C
• Heart rate 100 b/m
• Respiratory rate 24 t/m
• No lump at abdomen
• Liver and spleen are not palpable
• Muscles at lower quadrant are little tense
• Tenderness and rebound tenderness
• At McBurney point symptoms are more obvious
• Rovsing’s sign is +ive.
• No abdominal shifting
• Hypoactive bowel sound

3. Laboratory Test
• WBC
• Neutrophil to lymphocyte ratio 82:18
• RBC
• Hb 130g/L
• Urine is normal
• Stool is normal
L/1012 9
×
/L104.5 9
×

4. Acute Appendicitis

5. Common Symptoms of Appendicitis
• Abdominal pain
• Anorexia
• Nausea
• Vomiting
• Pain migration
Pain around the umbilicus
anorexia/nausea/unsustained vomiting
migration of pain to right lower quadrant
low-grade fever
Some time diarrhea

6. Common Signs of Appendicitis
• Right lower quadrant pain (the single most important sign)
• Low-grade fever (38°C [or 100.4°F])--absence of fever or high fever
can occur
• Peritoneal signs
• Rebound tenderness
• Guarding …tensing of muscles in response to touch.
• Tenderness on palpation in the RLQ over the McBurney point is the
most important sign in these patients

7. • Psoas sign--pain on extension of right thigh (retroperitoneal
retrocecal appendix)
• Obturator sign--pain on internal rotation of right thigh (pelvic
appendix)
• Rovsing's sign--pain in right lower quadrant with palpation of left
lower quadrant
•
• Dunphy's sign--increased pain with coughing
•
• Flank tenderness in right lower quadrant (retroperitoneal retrocecal
appendix)
•
• Patient maintains hip flexion with knees drawn up for comfort

8. Alvarado score
Symptoms
Migratory right iliac fossa pain 1 point
Anorexia 1 point
Nausea and vomiting 1 point
Signs
Right iliac fossa tenderness 2 points
Rebound tenderness 1 point
Fever 1 point
Laboratory
Leucocytosis 2 points
Neutrophilia 1 point
Total score 10 points
Score

9. Laboratory Test
• Increased WBC
• Neutrophilia
• Elevated C-reactive protein (>0.8 mg /dl)

10. . Ultrasonogram showing longitudinal section (arrows) of inflamed appendix

11. Differential Diagnosis

12. Differential Diagnosis
• In children:
– Gastroenteritis
– mesenteric adenitis
– Meckel's diverticulitis
– intussusception
– Henoch-Schönlein purpura
– lobar pneumonia
• In elderly:
– diverticulitis
– intestinal obstruction
– colonic carcinoma
– mesenteric ischemia
– leaking aortic aneurysm.

13. • In adults:
– regional enteritis
– renal colic
– perforated peptic ulcer
– pancreatitis
– rectus sheath hematoma
– in men:
• testicular torsion;
– in women:
• pelvic inflammatory disease
• ectopic pregnancy
• endometriosis
• torsion/rupture of ovarian cyst
• Mittelschmerz

14. Ectopic Pregnancy
• Pain in the lower abdomen, and
inflammation
• The pain commence on the right
side and stays there.
• Pain while urinating
• Pain while having a bowel
movement
• Pregnancy test is +ive.
• Bleeding
– Internal bleeding (Rupture of
effected tube)
– External bleeing (lowering of P.)

15. More sever Internal Bleeding
• Lower back, abdominal, or pelvic pain.
• Shoulder pain. This is caused by free blood tracking up the
abdominal cavity and irritating the diaphragm, and is an ominous sign.
• There may be cramping or even
tenderness on one side of the pelvis.

16. Pelvic Inflammatory Disease
♀ Pain is lower than appendicitis and
bilateral.
♀ Green or yellow vaginal discharge
♀ Irregular bleeding from vagina
♀ A laboratory test result confirming
gonorrhea or chlamydia
♀ Oral temperature of 38.3°C (101°F) or
higher
♀ Many white blood cells in vaginal or
cervical discharge
♀ Higher than normal erythrocyte
sedimentation rate (ESR) or C-reactive

17. ♀ pain during sexual intercourse or urination.
♀ Nausea
♀ vomiting.
♀ Elevated WBC in the blood
♀ Lower abdominal tenderness or pain
♀ Pain or tenderness when the ovaries or fallopian tubes
are touched or moved during examination
♀ Pain or tenderness when the cervix is touched or moved
during examination

18. Mittelschmerz
• Lower-abdominal pain that is:
– One-sided
– Recurrent or with similar pain in past
– Typically lasting minutes to a few hours, possibly as
long as 24-48 hours
– Usually sharp, cramping, distinctive pain
– May switch sides from month to month or from one
episode to another
– Begins midway through the menstrual cycle

19. Endometriosis
• A major symptom of endometriosis is recurring pelvic pain. The pain can
be mild to severe cramping that occurs on both sides of the pelvis, to the lower back and rectal
area and even down the legs
• dysmenorrhea – painful, sometimes disabling cramps; pain may get
worse over time (progressive pain), also lower back pains linked to
the pelvis
• chronic pelvic pain – typically accompanied by lower back pain or
abdominal pain
• dyspareunia – painful sex
• dyschezia – painful bowel movements
• dysuria – urinary urgency, frequency, and sometimes painful voiding

21. • nausea, vomiting, fainting, dizzy spells, diarrhea—particularly just prior to or
during the period or after
• frequent or constant menses flow
• chronic fatigue
• heavy or long uncontrollable menstrual periods with small or large blood
clots
• some women may also suffer mood swings
• extreme pain in legs and thighs
• Back pain
• extreme pain from frequent ovarian cysts
• extreme pain with or without the presence of menses
• mild to severe constipation

22. Ovarian Cyst
and
Rupture of Ovarian cyst

23. Symptoms and Signs
• Dull aching, or severe, sudden, and sharp pain or discomfort in the
lower abdomen (one or both sides), pelvis, vagina, lower back, or
thighs; pain may be constant or intermittent -- this is the most
common symptom
• Fullness, heaviness, pressure, swelling, or bloating in the abdomen
• Breast tenderness
• Pain during or shortly after beginning or end of menstrual period.
• Irregular periods, or abnormal uterine bleeding or spotting
• Change in frequency or ease of urination (such as inability to fully
empty the bladder), or difficulty with bowel movements due to
pressure on adjacent pelvic anatomy

24. • Weight gain
• Nausea or vomiting
• Fatigue
• Infertility
• Increased level of hair growth
• Increased facial hair or body hair
• Headaches
• Strange pains in ribs, which feel muscular
• Strange nodules that feel like bruises under the layer of Skin.

25. Renal Colic
• Commonly does not cause difficulty in
diagnosis because the character and
radiation of pain differ from appendicitis
• Pain in the loin region
• Radiate to groin region
• The pain is often colicky
• dull and acute
• Urinalysis.
– Hematuria

26. Perforated Peptic Ulcer
• Sudden and sever pain ( from epigastrium to
right paracolic gutter)
• Duodenal contents pass along the paracolic
gutter to iliac fossa.
• Shoulder pain
• Bowel sound is absent
• Liver dullness to percussion

27. Right Sided
Acute Pyelonephritis
• Accompained and preceded by increased
frequency of micturition.
• tenderness is confined to loin region.
• Fever 39 c
• Rigors and pyuria.

28. Acute Pancreatitis
• Urine and serum amylase

29. Rectus Sheath
Haematoma
• It is very rare
• Acute pain and localized tenderness in the
right illiac fossa, often after and epidodes
of strenous physical exercise.
• Mass is present.

30. Conclusion
• The patient is suffering from acute appendicitis

31. 2nd
part