The patient, a 15-year-old female, presented with abdominal pain and was found to have a ruptured appendix and periappendiceal abscess based on ultrasound findings. She underwent an appendectomy and drainage of the abscess. Her postoperative recovery was uneventful and she was discharged after one week with oral antibiotics.

1. 1
APPENDICITIS

2. PRESENTATION OUTLINE
 INTRODUCTION EPIDEMIOLOGY
 ETIOLOGY
 PATHOPHYSIOLOGY

3. INTRODUCTION
 SYMPTOMS AND SIGNS
 DIAGNOSIS
 PROGNOSIS
 TREATMENT
 CASE STUDY IN SOAPO
FORMAT
 REFERNCES
2

4.  Appendicitis is acute
inflammation of the
vermiform appendix, typically
resulting in abdominal anorexia, and
abdominal
tenderness.
 Diagnosis is
clinical, often supplemented by CT or
ultrasonography .
 Definitive
appendix.
pain ,
3

5. INTRODUCTION
treatment is surgical removal of the

6. INTRODUCTION
 Attached to the posteromedial
surface of the cecum is the blind,
wormlike appendix.
Roles of the Appendix
1. The appendix contains masses of
lymphoid tissue, and as part of MALT it plays an
important role in body immunity.
4

7. INTRODUCTION
2. Additionally, it serves as a storehouse of bacteria that
recolonize the gut when needed.

8. INTRODUCTION 5

9. INTRODUCTION 6

10. INTRODUCTION 7

11. EPIDEMIOLOGY
Study: Incidence of acute appendicitis in Kumasi,
Ghana (Ohene-Yeboah and Abatanga, 2009)

12. ETIOLOGY
Conclusion
 In Kumasi acute appendicitis
occurs in all age groups of both sexes.
 Males are more affected than females.
 Admission rates from the disease are
rising in both sexes most likely due
to increasing hospital attendance.
RISK FACTORS
1. Low fibre diet and high intake of refined foods.
8

13. bowel
diseases- Crohn
Intake
of indigestible seeds such
as guava seeds.
2. Inflammatory
Ulcerative colitis .
3. Constipation.
4.
Disease and
9

14. ETIOLOGY 10
 Appendicitis is thought to result from: obstructive causes
(mainly) and non-obstructive causes.
 Obstruction of the appendiceal lumen- typically by
lymphoid hyperplasia but occasionally by a fecalith, foreign
body, stricture, or even worms (pinworm).
 The obstruction leads to distention, bacterial
overgrowth, ischemia, and inflammation.

15.  If untreated, necrosis, gangrene, and
perforation occur.

16. ETIOLOGY
Fecalith: A hard stony mass of feces in
the intestinal tract Composition of
2. Calcium phosphate
3. Epithelial debris
4. Inspissated fecal matter
5. Foreign bodies (rarely)
11

17. the fecalith:
1. Bacteria

18. ETIOLOGY
Other obstructive causes
include: carcinoma caecum.
 Non-obstructive
Disease .
of the
diseases,
12

19. causes include: autoimmune
and conditions such as Ulcerative colitis and Crohn

20. ETIOLOGY
PATHOLOGY
 Obstructive-Primarily
 Mucocele of the appendix
 Rupture of the appendix
13

21.  Acute Appendicitis
 Phlegmonous mass/ Paracecal abscess

22. PATHOPHYSIOLOGY
1. Mucus+InflammatoryExudation= Increases pressure=
Obstructing lymphatic drainage.

23. 2.
submucosa.
distension)
4.
Edema+ Mucosal
Ulceration+ Bacterial
Translocation to the
3. Venous Obstruction (due to further
intraluminal appendiceal
Ischemia= Bacterial Invasion= Acute Appendicitis
intraluminal
14

24. SYMPTOMS AND SIGNS
PATHOPHYSIOLOGY
15

25. cavity.
6. Necrosis of the appendiceal wall.
7. Gangrenous appendicitis .
8. Perforation with free bacterial contamination of the peritoneal
The classic acute appendicitis symptoms are:

26. SYMPTOMS AND SIGNS
Epigastric or periumbilical pain followed by
brief nausea,
the pain shifts
to the
Pain increases with cough and motion
(Dunphy’s Sign).
1.
vomiting, and anorexia
2. After a few hours,
quadrant .
3.
right lower
16

27. SYMPTOMS AND SIGNS
Classic signs of appendicitis are:
1. Right lower quadrant direct and rebound
located at the McBurney point (junction of
the middle and outer thirds of the line
joining the umbilicus to the anterior
superior iliac spine).
tenderness
17

28. SYMPTOMS AND SIGNS
18
2. Additional appendicitis signs are pain felt in the right lower
quadrant with palpation of the left lower quadrant (Rovsing
sign)
3. An increase in pain caused by passive extension of the right hip
joint that stretches the iliopsoas muscle (psoas sign), or

29. SYMPTOMS AND SIGNS
4. Pain caused by passive internal rotation of the flexed thigh
5. Low-grade fever (rectal temperature
37.7 to 38.3° C [100 to
(obturator sign) .
101° F]) is common.

30. SYMPTOMS AND SIGNS 19

31. SYMPTOMS AND SIGNS 20

32. DIAGNOSIS
1. Clinical evaluation
2. Abdominal CT if necessary
3. Ultrasonography an option to CT
21

33. DIAGNOSIS
 Clinical evaluation
 The Alvarado score is a clinical scoring
system used in the diagnosis of
appendicitis.
 The score has 6 clinical
itemsand 2 measurements
with a total 10 points.
22
laboratory

34. DIAGNOSIS
 It was introduced in 1986 and although meant for pregnant
females, it has been extensively validated in the non-
pregnant population.
 The modified Alvarado score is at present in use.

35. DIAGNOSIS
 Clinical
23

36. DIAGNOSIS
evaluation

37. DIAGNOSIS
 Clinical evaluation Score <5:
 Score 5 or 6: Appendicitis
possible
 Score 7 or 8: Appendicitis
likely
 Score 9 or 10: Appendicitis
highly likely
The 2007 McKay study recommends CT scan for Alvarado 4-
6, surgical consultation for Alvarado > or =7, and for Alvarado
24

38. < or = 3, no CT for diagnosing appendicitis, as
appendicitis is unlikely.

39. DIAGNOSIS 25
 Clinical evaluation
 The Alvarado score has largely been superseded as a
clinical prediction tool by the Appendicitis
Inflammatory Response score Andersson
( et al,
2008; de Castro et al, 2012; Kollar et al, 2014).

40. DIAGNOSIS 26
 Clinical evaluation
AIR Score Risk Recommendation
0-4 Low Outpatient follow-up
(if unaltered general
condition)
5-8 Indeterminate In-hospital active
observation with serial
exams, imaging, or
diagnostic laparoscopy,
according to local
practice
9-12 High Surgical Exploration

41. DIAGNOSIS
 Laparoscopy canbe used for
diagnosis definitive treatment of
appendicitis; especially helpful in
women with lower abdominal pain
of unclear etiology.
 Laboratory studies typically show
leukocytosis (12,000 to 15,000/mcL [12.00 to 15.00 ×
109/L]), but this finding is highly variable.
27
as well as
it may be

42. 28
 NB: a normal white blood cell count
should not be used to exclude
appendicitis.
PROGNOSIS
 Without surgery or antibiotics (eg, in a remote location or
historically), the mortality rate for appendicitis is > 50%.
 With early surgery, the mortality rate is < 1%, and
convalescence is normally rapid and complete.

43.  With complications (rupture and
development of an abscess or peritonitis)
and/or advanced age, the prognosis is worse: Repeat
operations and a long convalescence may follow.

44.  Surgical removal of the
appendix
 IV fluids and antibiotics
 Treatment of acute appendicitis is
open or laparoscopic appendectomy;
because treatment delay mortality.
 The surgeon can usually remove the
appendix even if perforated. Occasionally, the appendix is
difficult to locate: In these cases, it usually lies behind the
cecum or the ileum and mesentery of the right colon.
29
increases

45. TREATMENT
TREATMENT
 A contraindicationto
appendectomy inflammatory
bowel disease involving
and/or terminal ileum.
 However, in cases of terminal ileitis
and a normal cecum, the appendix should be removed.
30
is
the cecum

46. 31
(Merck
not
 Appendectomy should be preceded by IV
antibiotics. Third-generation
cephalosporins are preferred (Merck Manual, 2018).
 For nonperforated appendicitis, no further antibiotics are
required.
 If the appendix is perforated,
antibiotics should be continued until the
patient’s temperature and white blood
cell count have normalized or continued
for a fixed course, according the
surgeon’s preference
to
Manual, 2018).
 If surgery is

47. TREATMENT
impossible, antibiotics—although
curative— markedly improve the survival rate.

48. TREATMENT 32
 Although several studies of nonoperative management of
appendicitis (ie, using antibiotics alone) have shown high
rates of resolution during the initial hospitalization, a
significant number of patients have a recurrence and
require appendectomy during the following year (Poon et
al., 2017).
 Thus appendectomy is still recommended.

49. TREATMENT 33
formed, the
ultrasound -guided
 When a large inflammatory mass is found involving the
appendix, terminal ileum, and cecum, resection of the
entire mass and ileocolostomy are preferable.
 In late cases in which a pericolic abscess has already
abscess is drained either by an percutaneouscatheteror
by

50. open operation (with appendectomy to follow
at a later date).- interval appendectomy.
CASE STUDY ON
RUPTURED APPENDIX

51. TREATMENT
WITH
SOAPO FORMAT
34

52. PERIAPPENDICEAL
ABSCESS

53. PATIENT INFORMATION
NAME OR LOGO 53
○Patient initials: D. O. A. ○Ward: C3 (General
○Admission Date: 10/06/2021 surgery Female)
○Admission time: 4:15pm ○Ethnicity: Akan
○Sex: Female ○Place of Residence:
SURGERY

54. PATIENT
INFORMATION
NAME OR LOGO 54
SURGERY
○Age: 15 yearsAbuakwa, Kumasi Presenting
complaints:
○ Abdominal pain-4/7.

55. PATIENT
INFORMATION
NAME OR LOGO 55
SURGERY
History of presenting complaints:
Patient was well until about 4 days prior to
presentation when she started having abdominal pain
after eating food bought from outside home. She
described her pain as a sudden-onset one emanating
from the right lumbar and iliac fossa,

56. PATIENT
INFORMATION
NAME OR LOGO 56
SURGERY
characteristically stabbing, radiating to the left iliac
fossa and with a pain severity score of 8/10. She was
sent to a peripheral hospital where she was given
some injection and medications (could not identify
injection and medications by their names). An
abdominopelvic ultrasound scan was taken which was
suggestive of bowel obstruction and appendiceal

57. PATIENT
INFORMATION
NAME OR LOGO 57
SURGERY
mass. She was then referred to KATH for further
management.
On Direct Questioning of the patient on 10/06/2021 :
○ Vomiting + (once),
○ Nausea (-),

58. PATIENT
INFORMATION
NAME OR LOGO 58
SURGERY
○ Fever (-),
○ Dysuria (-), diarrhea (-),
○ Constipation (-),Last menstrual period date
(08/06/2021) ○Social history: Patient is a JHS 3
student who lives with her parents and siblings.

59. PATIENT
INFORMATION
NAME OR LOGO 59
SURGERY
Patient neither smokes cigarette nor drinks alcohol.
Patient stays at Abuakwa, Kumasi, with her parents.
○Family history: Parents of patient do not have
any chronic disease. Her siblings also do not
have any chronic disease.

60. PATIENT
INFORMATION
NAME OR LOGO 60
SURGERY
○Past medical/surgical history: Patient does not
have any chronic disease. Patient has not
undergone any major or
minor surgery since birth.

61. PATIENT
INFORMATION
NAME OR LOGO 61
SURGERY
○Drug history: Patient could not recollect the
names of the medications that were given to her
at the peripheral hospital. Her referral form did

62. PATIENT
INFORMATION
NAME OR LOGO 62
SURGERY
not contain the names of the medications given
to her.
Relevant signs upon presentation at C3 ward

63. PATIENT
INFORMATION
NAME OR LOGO 63
SURGERY
○ On Examination: Patient is a female adolescent,
not warm to touch (body temperature of
36.5degrees

64. PATIENT
INFORMATION
NAME OR LOGO 64
SURGERY
celsius), not pale, and anicteric. Her hydration
status was good.
Relevant signs upon presentation

65. PATIENT
INFORMATION
NAME OR LOGO 65
SURGERY
Respiratory system:
○ Airway: Patent.
○ Breathing: Respiratory Rate (22cpm), SpO2
(100% on

66. PATIENT
INFORMATION
NAME OR LOGO 66
SURGERY
room air), chest clinically clear, no abrasions
on chest, no chest compression or tenderness
Relevant signs upon presentation
Cardiovascular system

67. PATIENT
INFORMATION
NAME OR LOGO 67
SURGERY
○ Circulation: BP (131/78mmHg); Pulse
(120bpm);
s1+s2+0
Relevant signs upon presentation Gastrointestinal
System o Abdomen- Abdomen was full, moves with

68. PATIENT
INFORMATION
NAME OR LOGO 68
SURGERY
respiration. Umbilicus was flat. There was tenderness at
the right iliac fossa with guarding and rebound
tenderness. There was also a mass at the right iliac

69. PATIENT
INFORMATION
NAME OR LOGO 69
SURGERY
fossa however, other features of the mass could not be
appreciated because of the tenderness.
Relevant signs upon presentation
Central Nervous System

70. PATIENT
INFORMATION
NAME OR LOGO 70
SURGERY
○ GCS-15/15, PERRL (+)
○ Patient had a normal gait.

71. NAME OR LOGO 71
SURGERY
VITAL SIGNS

72. NAME OR LOGO 72
SURGERY

73. INVESTIGATIONS
NAME OR LOGO 73
SURGERY
VITAL SIGNS
1. Abdominopelvic Ultrasound Scan-
10/06/2021

74. NAME OR LOGO 74
SURGERY
2. Complete Blood Count- 10/06/2021
3. Renal Function Test- 10/06/2021
4. Serum Electrolyte Levels- 10/06/2021

75. INVESTIGATIONS
NAME OR LOGO 75
SURGERY
1.Abdominopelvic Ultrasound Scan- 10/06/2021
Conclusion of Report:
○There is the presence of a right iliac fossa mass
(appendiceal mass).

76. INVESTIGATIONS
NAME OR LOGO 76
SURGERY
2.Complete Blood Count (10-06-2021)
PARAMETER NORMAL ABNORMAL UNITS REFERENCE
RANGE
WBC 13.36 H 10^3/ul 4.00-10.00
RBC 4.40 10^6/ul 3.80-5.20
HGB 12.00 g/dl 12.00-15.00
HCT 36.7 % 35.00-46.00
MCV 83.4 fL 77.00-97.00
MCH 27.3 pg 26.00-34.00

77. INVESTIGATIONS
NAME OR LOGO 77
SURGERY
MCHC 32.7 g/dl 32.00-35.00
PLT 104 L 10^3/ul 150.00-400.00
○ Complete Blood Count
PARAMETER NORMAL ABNORMAL UNITS REFERENCE
RANGE
MPV 11.4 fL 8.00-11.00
RDW-SD 41.3 fL 37.00-49.00
RDW-CV 13.5 % 11.00-22.00
PCT 0.12 L % 0.17-0.35

78. INVESTIGATIONS
NAME OR LOGO 78
SURGERY
PDW 14.8 fL 11.00-22.00
NEU# 10.70 H 10^3/ul 1.60-7.00
LYMPH# 1.58 10^3/ul 1.00-4.00
MON# 0.98 10^3/ul 0.20-1.20
○ Complete Blood Count
PARAMETER NORMAL ABNORMAL UNITS REFERENCE
RANGE
EOS# 0.05 10^3/ul 0.0-0.50
BAS# 0.05 10^3/ul 0.00-0.30

79. INVESTIGATIONS
NAME OR LOGO 79
SURGERY
NEU% 80.1 H % 40.00-73.00
LYM% 11.8 L % 20.00-45.00
MON% 7.3 % 4.00-12.00
EOS% 0.4 % 0.00-7.00
BAS% 0.4 % 0.00-2.00
P-LCR 35.2 % 13.00-43.00
○Complete Blood Count
PARAMETER NORMAL ABNORMAL UNITS REFERENCE
RANGE

80. INVESTIGATIONS
NAME OR LOGO 80
SURGERY
MicroR 1.2 % 0.00-100.00
MacroR 4.90 % 0.00-100.00
IG# 0.05 H 10^3/ul 0.00-0.04
IG% 0.4 % 0.0-0.6
3.Renal Function Test (10-06-2021)
PARAMETER NORMAL ABNORMAL UNITS REFERENCE
RANGE
Urea 1.63 L mmol/L 2.50-8.30
Creatinine 37.00 L mmol/L 44-80

81. INVESTIGATIONS
NAME OR LOGO 81
SURGERY
Urea to 20.80
Creatinine ratio
8.0-35.0
4.Serum Electrolyte Levels (10-06-2021)
○10PARAMETER-
06-2021
NORMAL ABNORMAL UNITS
REFERENCE
RANGE
Sodium 144.1 mmol/L 135-145
Potassium 4.54 mmol/L 3.5-5.5
Chloride 111.8 H mmol/L 90.0-107.0

82. CURRENT MEDICATIONS
82
Drug/(Strength)/Dose/Route Dosage regimen Start Date Stop Date Reason for
Use
Comment
Morphine/(10mg/ml)/IV 10mg stat, then 10/06/2021
11/06/2021
5mg 6hourly
To relieve
abdominal
pain
Appropriate
Morphine/(10mg/ml)/IV 10mg 8hourly 12/06/2021
13/06/2021
To relieve
pain at
surgical
incision
site
Appropriate

83. CURRENT MEDICATIONS
NAME OR LOGO 83
SURGERY
Paracetamol/ (1g/100ml)/IV 1g 8hourly 10/06/2021 14/06/2021 To relieve
abdominal
pain
Appropriate

84. CURRENT MEDICATIONS
84
NAME OR LOGO
SURGERY
Drug/(Strength)/Dose/Route
Dosage
regime
n
Start Date Stop Date Reasonfor Use Comment
Ciprofloxacin/ (400mg/100ml)/IV
400
mg
12hourly
10/06/2021 14/06/2021 To treat gram negative
and gram positive
bacterial infections as a
result of a ruptured
appendix with
periappendiceal abscess
Appropriat
e
Metronidazole/ (500mg/100ml)/IV
500
mg
8hourly
10/06/202
1
14/06/2021 To treat anaerobic
bacterial infections as a
result of a ruptured
appendix with
periappendiceal abscess
Appropriat
e

85. CURRENT MEDICATIONS
NAME OR LOGO 85
SURGERY
Drug/(Strength)/Dose/Route Dosage
regimen
Start Date Stop Date Reason for Use
Comment
Ringer’s Lactate//IV 500ml
6hourly
10/06/2021 14/06/2021 For hydration and
Appropriate
electrolyte
replenishment
Normal Saline/(0.9% w/v)/IV 500ml 10/06/202 11/06/2021 For hydration and
Appropriate
12hourly 1 electrolyte

86. CURRENT MEDICATIONS
86
replenishment

87. CURRENT MEDICATIONS
NAME OR LOGO 87
SURGERY
Drug/(Strength)/Dose/Route Dosage
regimen
Start Date Stop Date Reason for Use
Comment
Dextrose (5%w/v) in Normal
Saline// IV
500ml daily 10/06/2021 11/06/2021 For nutrition,
Appropriate
electrolyte
replenishment and
hydration therapy
Dextrose/ (5% w/v)/ IV 500ml 8 hourly 12/06/2021 14/06/2021 For nutrition and
Appropriate hydration therapy

88. SURGERY DETAILS
NAME OR LOGO 88
SURGERY
MEDICAL DIAGNOSIS
1. Ruptured appendix with Periappendiceal
Abscess.

89. NAME OR LOGO 89
SURGERY
Date Of Surgery: 11-06-2021
Duration Of Surgery: 1 Hour
Surgical Procedure: Evacuation Of 100ml Of Perippendiceal
Abscess

90. SURGERY DETAILS
NAME OR LOGO 90
SURGERY
And Appendicectomy
Operation Theatre: Main
Theatre
Consultant: Prof. Joseph
Yorke
Surgeon: Dr. Francis A.
Yamoah

91. NAME OR LOGO 91
SURGERY
Assistant: Dr. Rawuf
Mohammed
Anaesthesiologist: Dr.
Tweneboah
Intra-opFindings: Ruptured Appendix With About 100ml Of
Perippendiceal Abscess

92. SURGERY DETAILS
NAME OR LOGO 92
SURGERY
PROCEDURE DETAILS:
Under aseptic conditions and general endotracheal
anaesthesia, the patient was placed in the supine position with
her arms abducted at 90degrees. Her abdomen was cleaned
and draped. A lower midline incision was made to access the
peritoneal cavity and the findings were as stated above. The
abscess was evacuated. The mesoappendix was ligated at the

93. SURGERY DETAILS
NAME OR LOGO 93
SURGERY
base followed by clamping, ligation and excision of the
appendix at the base. The cavity was washed with 2L of warm
normal saline. The abdominal incisions were closed in layers.
The incised skin was sutured with Vicryl 2-0.
The patient’s post-operative condition was satisfactory.
POST-OPERATIVE MANAGEMENT:

94. SURGERY DETAILS
NAME OR LOGO 94
SURGERY
○MONITOR VITALS EVERY 15MINUTES UNTIL FULL RECOVERY FROM
ANAESTHESIA. INTRAVENOUS FLUID MAINTENANCE SHOULD BE CONTINUED.
CONTINUE IV ANTIBIOTICS AND ANALGESICS. PROVIDE PATIENT
SUPPLEMENTAL OXYGEN AND TRANS OUT TO C3 WARD WHEN SHE HAS
FULLY RECOVERED FROM ANAESTHESIA.

95. SURGERY DETAILS
NAME OR LOGO 95
SURGERY
WOUND DRESSING OF SURGICAL INCISION SITE
○ First wound dressing of surgical incision site was performed
on 13/06/2021. It was then dressed every 2 days,
thereafter.
○ Patient was advised to come to the hospital every other day
for wound dressing.

96. SURGERY DETAILS
NAME OR LOGO 96
SURGERY
Wound dressing is done aseptically, and involves two
individuals; the aseptic nurse and the assistant.
The assistant is responsible for handing all necessary materials
to the aseptic nurse, who primarily is in contact with the
wounds.
• The soaked gauze is removed and discarded.
• The wound is cleaned with a normal saline soaked gauze.

97. SURGERY DETAILS
NAME OR LOGO 97
SURGERY
• The wound surface is then secured with another gauze pack
soaked in povidone-iodine.
• The wound is then packed with a gauze and secured with
plaster.
• The used materials are then appropriately discarded.

98. NAME OR LOGO 98
SURGERY
DISCHARGE MEDICATIONS
Drug/(Strength)/Dose/Route
Dosage
regimen
Start Date Stop Date Reasonfor Use Comment
Ciprofloxacin/(500mg)/500mg
/Oral
500
mg
12hourly
15/06/2021 19/06/2021To treat gram
negative and gram
positive bacterial
infections as a result
of a ruptured
appendix with
periappendiceal
abscess
Appropriate
Metronidazole/(400mg)/400m
g/Oral
400
mg
every
8hours
15/06/2021 19/06/2021To treat anaerobic
bacterial infections as
a result of a ruptured
appendix with
periappendiceal
abscess
Appropriate

99. NAME OR LOGO 99
SURGERY
DISCHARGE MEDICATIONS
Drug/(Strength)/Dose/Rou
te
Dosage
regimen
Start Date Stop
Date
Reasonfor Use Comment
Ibuprofen/(400mg)/400m
g/ Oral
mg
400
every 8
hours
16 06/202
/
1
20/06/
2
021
To relieve pain
at surgical
incision
Appropria
te

100. NAME OR LOGO 10
SURGERY
PHARMACEUTICAL CARE ISSUE

101. NAME OR LOGO 10
SURGERY
○ An oral analgesic was not initially provided in
addition to the oral antibiotic therapy for the

102. NAME OR LOGO 10
SURGERY
patient upon hospital discharge.

103. 10
OPTIMIZING THE MANAGEMENT
OF
RUPTURED APPENDIX WITH
PERIAPPENDICEAL ABSCESS
SURGERY

104. NAME OR LOGO 10
SURGERY
SUBJECTIVE DATA
○Abdominal pain with a pain severity score of
8/10 - 4/7.
○Patient described her abdominal pain as
radiating from the right iliac fossa.

105. NAME OR LOGO 10
SURGERY
○Patient vomited (once) before presenting to the
Hospital.
OBJECTIVE DATA

106. NAME OR LOGO 10
SURGERY
• Abdominopelvic ultrasound scan conducted on 10-
06-2021 indicated the presence of right iliac fossa
mass
(appendiceal mass).
• Also, the Complete Blood Count conducted on 10-
06-2021, indicated the presence of elevated white
blood cell count of

107. NAME OR LOGO 10
SURGERY
13.36x10^3cells/ul, with a differential neutrophil
count of 10.7x10^3cells/ul, indicating the
presence of ongoing inflammation or
uncontrolled bacterial proliferation in the
appendix.

108. NAME OR LOGO 10
SURGERY
• Intra-operative findings revealed a ruptured
appendix with about 100ml of periappendiceal
abscess.

109. ASSESSMENT
CONFIRMATION OF DIAGNOSIS
NAME OR LOGO 10
SURGERY
○According to the Merck Manual (2018), Appendicitis is defined
as an acute inflammation of the vermiform appendix,
characteristically resulting in anorexia, abdominal pain, and
abdominal tenderness. Diagnosis is usually clinical, that is,
based on patient’s medical history and clinical examinations
and findings. Diagnosis is also often supplemented by
abdominopelvic CT or ultrasonography.

110. ASSESSMENT
CONFIRMATION OF DIAGNOSIS
NAME OR LOGO 11
SURGERY
○Definitive treatment is surgical removal of the appendix (Kumar
and Clark, 2017).
○Appendicitis can lead further lead to rupturing of the appendix,
periappendiceal abscess (es) or peritonitis, if not identified
earlier for medical management (Merck Manual, 2018).

111. ASSESSMENT
CONFIRMATION OF DIAGNOSIS
NAME OR LOGO 11
SURGERY
○ According to the Centre for Disease Control and Prevention
(CDC), a ruptured appendix with periappendiceal abscess is
classified as a dirtyinfected (class IV) wound. Thus, it is highly
probable that gut bacteria present in the ruptured appendix
are responsible for the pus formed.
○ The subjective data of the patient indicated therein, Abdominal
pain with a pain severity score of 8/10 for 4 days. She

112. ASSESSMENT
CONFIRMATION OF DIAGNOSIS
NAME OR LOGO 11
SURGERY
described that her abdominal pain was radiating from the
right iliac fossa. She vomited (once) before presenting to the
Hospital.
○ The objective data of the patient indicated therein that an
Abdominopelvic ultrasound scan conducted on 10-06-2021
indicated the presence of right iliac fossa mass (appendiceal
mass).

113. ASSESSMENT
CONFIRMATION OF DIAGNOSIS
NAME OR LOGO 11
SURGERY
○ Also, the Complete Blood Count conducted on 10-06-2021,
indicated the presence of elevated white blood cell count of
13.36x10^3cells/ul, with a differential neutrophil count of
10.7x10^3cells/ul, indicating the presence of ongoing
inflammation or uncontrolled bacterial proliferation in the
appendix.

114. ASSESSMENT
CONFIRMATION OF DIAGNOSIS
NAME OR LOGO 11
SURGERY
○ Intra-operative findings revealed a ruptured appendix with
about 100ml of periappendiceal abscess.
○ Thus, based on the aforementioned subjective and objective
data, the diagnosis of Ruptured Appendix with
Periappendiceal Abscess is appropriate in this patient.

115. ASSESSMENT
NAME OR LOGO 11
SURGERY
APPROPRIATENESS OF MEDICATIONS
TREATMENT OBJECTIVES
1. To provide adequate analgesia due to the abdominal pains.
2. To provide effective antibiotic treatment for ruptured appendix with
periappendiceal abscess.
3. To prevent the occurrence the complications of ruptured appendix, such
as, peritonitis, in this patient.

116. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 11
SURGERY
4. To prepare patient adequately for surgical intervention(s) as timely as
possible.
4. To adequately rehydrate the patient and provide nutrition for the patient
with the use of
IV fluids.
5. To improve upon the quality of life of the patient.

117. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 11
SURGERY
Morphine IV 10mg stat, then 5mg 6hourly for 2 days followed
by 10mg 8hourly 3days
○ Opioids are usually the backbone of severe acute pain
management. Morphine acts on a number of receptors
including the Mu1, Mu2, kappa and delta to exert its
analgesic effects (Flower et al, 2012).

118. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 11
SURGERY
○ According to the World Health Organization Analgesic
Ladder, strong opioids such as morphine are indicated for
moderate to severe postoperative pain (Wilkinson et al,
2017).
Morphine IV 10mg stat, then 5mg 6hourly for 2 days followed
by 10mg 8hourly 3days

119. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 11
SURGERY
○ Thus, the use of IV morphine for the management of
moderate to severe postoperative abdominal pain is
appropriate in this patient. The doses and frequencies of IV
Morphine are appropriate in this patient (British National
Formulary, 80th Edition).
Ciprofloxacin IV 400mg every 12 hours for 5 days, followed by
Ciprofloxacin Oral 500mg every 12hours for 5 days

120. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 12
SURGERY
○ Antibiotics for lower gastrointestinal infections due to
periappendiceal abscess should have coverage against
gram-negative organisms and anaerobes, and the choice of
a specific agent should be determined by local susceptibility
and availability (Jackson and Raiji, 2011).
○ Ciprofloxacin is a potent bactericidal agent against gram-
negative bacteria such as Proteus mirabilis, E. coli,

121. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 12
SURGERY
Klebsiella spp., and various species of Salmonella, Shigella,
Enterobacter, and Campylobacter which are most
commonly implicated in lower gastrointestinal infections
(Brunton et al, 2018).
Ciprofloxacin IV 400mg every 12 hours for 5 days, followed by
Ciprofloxacin Oral 500mg every 12hours for 5 days

122. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 12
SURGERY
○ The elimination half-life of ciprofloxacin is 5hours and so it
is typically dosed 12hourly, with the exception of an
extended-release formulation, which can be dosed once
daily (Merck Manual, 2018).
○ Thus, IV Ciprofloxacin 500mg administered as a slow IV
infusion (60minutes) 12hourly for the treatment of a lower
gastrointestinal infection due to ruptured appendix with

123. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 12
SURGERY
periappendiceal abscess is appropriate (British National
Formulary, 80th Edition; Gahart et al, 2018).
Ciprofloxacin IV 400mg every 12 hours for 5 days, followed by
Ciprofloxacin Oral 500mg every 12hours for 5 days
○ Also, the duration of therapies (for both IV and oral) are
appropriate for the treatment of a lower gastrointestinal

124. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 12
SURGERY
infection caused by gramnegative bacteria due to ruptured
appendix with periappendiceal abscess (Gahart et al, 2018).

125. ASSESSMENT
NAME OR LOGO 12
SURGERY
APPROPRIATENESS OF MEDICATIONS
Metronidazole IV 500mg every 8 hours for 5 days, followed
by Metronidazole Oral 400mg every 8 hours for 5 days
○ Metronidazole manifests antibacterial activity against all
anaerobic cocci; anaerobic gram-negative bacilli, including
Bacteroides spp.; anaerobic spore-forming, gram-positive
bacilli such as Clostridium; and microaerophilic bacteria

126. ASSESSMENT
NAME OR LOGO 12
SURGERY
such as Helicobacter and Campylobacter spp. (Lofmark et
al, 2010).
○ Thus, Metronidazole is appropriate for the treatment lower
gastrointestinal tract infections due to ruptured appendix
with periappendiceal abscess (Jackson and Raiji, 2011).
APPROPRIATENESS OF MEDICATIONS

127. ASSESSMENT
NAME OR LOGO 12
SURGERY
Metronidazole IV 500mg every 8 hours for 5 days, followed
by Metronidazole Oral 400mg every 8 hours for 5 days
○ Thus, IV Metronidazole 500mg administered as a slow IV
infusion (30minutes) 8hourly is appropriate for the
treatment of a lower gastrointestinal infection due to
ruptured appendix with periappendiceal abscess (British
National Formulary, 80th Edition; Gahart et al, 2018).

128. ASSESSMENT
NAME OR LOGO 12
SURGERY
○ Also, the duration of therapies (for both IV and oral) are
appropriate (Gahart et al, 2018).
APPROPRIATENESS OF MEDICATIONS
Paracetamol Oral 1g every 8 hours for 5 days
○ Paracetamol is a nonselective COX inhibitor, which acts at the peroxide
site of the enzyme and is thus distinct from NSAIDs. Thus, the
presence of high concentrations of peroxides, as occur at sites of

129. ASSESSMENT
NAME OR LOGO 12
SURGERY
inflammation, reduces its COX-inhibitory activity (Brunton et al.,
2018).
○ According to the Standard Treatment Guidelines (STG) 2017 and the
World Health Organization Analgesic ladder, paracetamol is indicated
for mild-to-moderate pain.
○ Thus, the use of Paracetamol IV at a dose of 1g every 8 hours for 5
days for the management of abdominal pain associated due to

130. ASSESSMENT
NAME OR LOGO 13
SURGERY
ruptured appendix with periappendiceal abscess is appropriate in this
patient (Standard Treatment Guidelines, 2017).
APPROPRIATENESS OF MEDICATIONS
Normal Saline IV 500ml every 12hours for 5days
○Normal saline is a cornerstone of intravenous solutions
commonly employed in clinical settings. It is a crystalloid
fluid. It is administered as an intravenous solution. Its

131. ASSESSMENT
NAME OR LOGO 13
SURGERY
indications include both adult and pediatric populations as
sources of hydration and electrolyte disturbances (Tonog
and Lakhkar, 2020).
○Intravenous Normal saline is an essential method of
hydration of patients who are especially booked for
gastrointestinal tract surgery. This is because, such patients
are normally kept nil per os.

132. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 13
SURGERY
Normal Saline IV 500ml every 12hours for 5days
○Thus, the only means to hydrate such patients is by the
intravenous route. Also, it is essential to replace lost body
fluids after surgery.
○However, because it may take some time for patients to start
oral fluid intake after surgeries (more particularly, surgeries
involving the gastrointestinal tract), it is important that

133. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 13
SURGERY
intravenous fluid therapy is provided for such patients until
they begin to take fluids orally.
○Thus, crystalloid solutions remain the fluid of choice for
replacement and maintenance fluid therapy following surgery
(Merck Manual, 2018; Martin et al, 2020).
Normal Saline IV 500ml every 12hours for 5days

134. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 13
SURGERY
○Thus, the use of Normal saline at a volume of 500ml every 12
hours for 5 days, in addition to other intravenous fluids (1 day
before and 4 days after surgery) is appropriate for hydration
in this patient (Merck Manual, 2018).
Ringer’s lactate IV 500ml every 12hours for 1day.

135. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 13
SURGERY
○Ringer's lactate solution is very often used for fluid
resuscitation after a blood loss due to trauma, surgery, or a
burn injury (Tonog and Lakhkar, 2020).
○Also, it is used for the replacement of electrolyte loss and
maintenance of normal electrolyte balance in patients,
especially, for those who cannot take fluids orally, such as
patients who are about to undergo surgery or have undergone

136. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 13
SURGERY
surgery, and those who are vomiting (Tonog and Lakhkar,
2020).
Ringer’s lactate IV 500ml every 12hours for 1day.
○Ringer's lactate has an osmolarity of 273 mOsm L−1 and a pH
of 6.5. Unlike Normal Saline, Ringer’s lactate provides
potassium, calcium and lactate which are vital for the
metabolic processes of the body (Gahart et al, 2018).

137. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 13
SURGERY
○Thus, the use of Ringer’s lactate at a volume of 500ml, 6 hourly
for 5 day in addition to other intravenous fluids (1 day before
and 4 days after surgery) is appropriate for hydration in this
patient (Gahart et al, 2018).
○Thus, based on the clinical presentation of the patient, Ringer’s
lactate is appropriate for electrolyte maintenance and

138. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 13
SURGERY
hydration of the patient (British National Formulary, 80th
Edition).
Dextrose (5%) in Normal Saline IV 500ml every 8hours for
2days.
○Dextrose (5%) in Normal Saline provides calories and fluid
replacement by peripheral infusion when calories and fluid are

139. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 13
SURGERY
required, especially in dehydrated patients and in patients who
have had recent frequent vomits (Gahart et al, 2018).
○It acts as a fluid and nutrient replenisher. Thus, it is an
important source of nutrition for patients who are kept nil per
os because of a planned surgery.

140. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 14
SURGERY
○Thus, Dextrose (5%) in Normal Saline IV 500ml, 12hourly for
2days (1day before surgery and 1 day after surgery) is
appropriate for this patient (Jackson and Raiji, 2011).
Dextrose (5%) IV 500ml every 8hours for 3days
○Dextrose 5% in water is indicated for the treatment of
hypoglycemia, insulin shock, or dehydration (fluid loss).
Dextrose 5% in water is also administered for nutritional

141. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 14
SURGERY
support to patients who are not able to eat because of illness,
injury, or other medical condition such as surgery. Because,
patients who have undergone gastrointestinal surgery are
usually kept nil per os, it is vital that they are provided with
adequate nutritional support via the intravenous route until
they begin to accommodate oral nutrition (Tonog and Lakhkar,
2020).

142. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 14
SURGERY
○Thus, Dextrose (5%) in Normal Saline IV 500ml, 8hourly for
3days after surgery is appropriate for this patient (British
National Formulary, 80th Edition).
Ibuprofen Oral 400mg every 8 hours for 5days
Ibuprofen is an effective non-steroidal anti-inflammatory drug
(NSAID) which is considered as one of the NSAIDs with minimal
gastric-irritating properties. Thus, it is suitable as an oral

143. ASSESSMENT
APPROPRIATENESS OF MEDICATIONS
NAME OR LOGO 14
SURGERY
analgesic for the relief of pain at the incision site of the patient.
It can also help reduce the level of inflammation associated with
the incision site (Whittlesea and Hodson, 2019).
Thus, Ibuprofen Oral 400mg every 8 hours for 5days (to begin
3days after surgery) is appropriate for this patient (British
National Formulary, 80th
Edition).

144. PLAN
NAME OR LOGO 14
SURGERY
MONITIORING
MEDICATION EFFICACY TOXICITY
Morphine, IV Absence of pain
abdominal pain and pain
at the surgical incision
site
Constipation, Nausea,
Pruritus
MEDICATION EFFICACY TOXICITY

145. PLAN
MONITIORING
NAME OR LOGO 14
SURGERY
Ciprofloxacin, IV, Oral
Absence of abdominal pain,
absence of elevated neutrophil
count, absence of swelling,
redness or pus at surgical
incision site
Pyrexia (Body temperature
above 37.5degrees celsius),
Nausea and Vomiting,
Abdominal pain, Swelling,
redness or pus at surgical incision
site.
Metronidazole, IV, Oral Absence of abdominal pain, Pyrexia (Body temperature absence
of elevated neutrophil above 37.5degrees celsius), count,
absence of swelling,
Nausea and Vomiting,
redness or pus at surgical
incision site Abdominal pain, Swelling,

146. PLAN
MONITIORING
NAME OR LOGO 14
SURGERY
redness or pus at surgical incision
site
MEDICATION EFFICACY TOXICITY
Paracetamol, IV Absence of pain
abdominal pain and pain
at the incision site
Acute Liver failure
(deranged liver enzymes
in Liver function test),
tachycardia (Heart rate
above 100 beats per
minute)

147. PLAN
MONITIORING
NAME OR LOGO 14
SURGERY
Normal Saline, IV, Volume overload (eye
puffiness), Consistently
raised blood pressure
Volume overload (eye
puffiness), Consistently
raised blood pressure
MEDICATION EFFICACY TOXICITY
Ringer’s Lactate, IV Adequate hydration
maintained
Volume overload (eye
puffiness), Consistently raised
blood pressure
Dextrose (5%) in Normal Adequate nutrition and Volume overload (eye
Saline, IV hydration achieved puffiness), Consistently raised
blood pressure

148. PLAN
MONITIORING
NAME OR LOGO 14
SURGERY
MEDICATION EFFICACY TOXICITY
Dextrose (5%), IV Adequate nutrition
and hydration
achieved
Volume overload (eye
puffiness), Consistently
raised blood pressure
Ibuprofen, Oral Absence of pain Dyspepsia, Nausea, abdominal pain and
Vomiting
pain at the incision site

149. PLAN
NAME OR LOGO 14
SURGERY
COUNSELLING ON MEDICATIONS
Patient was counselled by educating her on the role of each of her
medications.
Oral Ciprofloxacin use : Patient was counselled to
○ Take medication at least 1 hour before meals.
○ Take medication with a glass full of water in order to avoid crystal
formation and deposition in the kidneys.

150. PLAN
NAME OR LOGO 15
SURGERY
○ Avoid milk, or dairy products (foods that contain milk), antacids or
medicines containing iron or zinc, 2 hours before or after taking this
medicine.
○ Keep taking this medicine until the course is finished.
○ Space doses evenly throughout the day.
○ Report any serious side-effects to the doctor who prescribed the
medication for her

151. PLAN
NAME OR LOGO 15
SURGERY
Oral Metronidazole use : Patient was counselled to
○ Avoid alcohol whilst on antibiotic therapy with
medication.
○ Space doses evenly throughout the day.
○ Keep taking this medicine until the course is finished.
○ Take with or just after food, or a meal.

152. PLAN
NAME OR LOGO 15
SURGERY
○ Take medication with a glass full of water in order to avoid
crystal formation and deposition in the kidneys.
○ Report any serious side-effects to the doctor who prescribed
the medication for her.
Oral Ibuprofen use : Patient was counselled to
○Take with or just after food, or a meal
○Space doses evenly throughout the day.

153. PLAN
NAME OR LOGO 15
SURGERY
○Report any serious side-effects to the doctor who prescribed
the medication for her.
COUNSELLING ON NON-PHARMACOLOGICAL MOETHODS OF
MANAGING MEDICAL CONDITION
○ Patient was counselled to eat a well-balanced diet every day. Patient was
counselled to take meals rich in proteins like beans, eggs, and red meat
in order to speed up her wound healing process.

154. PLAN
NAME OR LOGO 15
SURGERY
○ Patient was counselled to increase her daily intake of fluids to at least 3
litres a day in order to prevent constipation which will impede her wound’s
healing progress.
○ Patient was counselled on the maintenance of personal hygiene in order to
prevent her wound from getting infected by microbes.
○ The patient was advised to incorporate food products with high fibre such
as oats and beans in her diet to prevent further incidences of constipating.

155. PLAN
NAME OR LOGO 15
SURGERY
○ The patient was counselled on safe practices to keep the surgical site clean,
such as careful dry bathing around the surgical incision site.

156. NAME OR LOGO 15
SURGERY
OUTCOME
RECOMMENDATIONS/INTERVENTION
○The recommendation made was accepted. Oral ibuprofen
400mg 8 hourly for 5days was added to the oral antibiotic
therapy (discharge medications) of the patient.

157. NAME OR LOGO 15
SURGERY
OUTCOME
○The patient’s abdominal pain started resolving after the
surgery (evacuation of the periappendiceal abscess and
appendicectomy), though she had moderate pain of intensity
of 5/10 at the surgical incision site. The patient was
discharged on 15th June, 2021.

158. NAME OR LOGO 15
SURGERY
○The patient was informed to
attend to the hospital every other day for wound dressing since
she lived quite close to the hospital.
○The patient was healthy and well-looking upon discharge from
the hospital.
ROLE OF THE PHARMACIST

159. NAME OR LOGO 15
SURGERY
○ Provided adequate Information to the patient about her conditions, the
important nonpharmacological treatments (diet) to perform and the
essence of adherence to medication therapy in order to prevent
complications to her.
○ Made contributions to the medical team with regards to the selection of
appropriate medications required to manage optimum antimicrobial
therapy for the patient with considerations for safety of the drugs of choice.

160. NAME OR LOGO 16
SURGERY
○ Assisted in keeping to right
timing of administration of medications with emphasis on not increasing
doses should a particular dose of medication is missed. Timing schedules
were made flexible to the advantage of the patient.
○ Monitored the potential adverse effects such as volume overload as a result
of IV hydration (medical) therapy.

161. NAME OR LOGO 16
SURGERY
ROLE OF THE PHARMACIST
○ Performed medication review every day to make sure prescribed
medications were administered correctly and patient was compliant with
therapy.
○ Performed discharge counselling on medications as well as need for
outpatient monitoring of any signs and symptoms.

162. REFERENCES
SURGERY NAME OR LOGO 162
○ Counselled the patient to visit the health facility should prognosis of her
medical conditions worsen in spite of adherence to therapy
○ Advised the patient to report any side effect(s) of medication therapy.
British National Formulary, 80th Edition, Pharmaceutical Press,
London, U.K. Pages 572, 590 and 1198.

163. REFERENCES
SURGERY NAME OR LOGO 163
Brunton L.L. et al (ed.) (2018) Goodman & Gilman’s: The
Pharmacological basis of Therapeutics (13th Edition). McGraw-Hill
Education. New York, USA. Pages 1015-1017 and 1068.
McLatchie et al., (2013) Oxford Handbook of Surgery (4th Edition).
Oxford University Press. Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom. Pages 298 and 299.

164. REFERENCES
SURGERY NAME OR LOGO 164
Porter, R. S. et al, (ed.) (2018). The Merck Manual of Diagnosis and
Therapy.
20th Edition. Whitehouse Station, N.J.: Merck Sharp & Dohme Corp.
USA. Pages 88 and 89.
Whittlesea C. and Hodson K. (ed.), (2019), Clinical Pharmacy and
Therapeutics, 6th Edition. Churchill Livingstone Elsevier. London,
United Kingdom. Pages 176 and 177.

165. REFERENCES
SURGERY NAME OR LOGO 165
Gahart B.L. et al (2018), Gahart's 2018 Intravenous Medications: A
Handbook for Nurses and Health Professionals (34th Edition)
Elsevier Inc. London, United Kingdom. Pages 445-447.
Tonog P., Lakhkar A.D., Normal Saline. [Updated 2020 May 24]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;
2020 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK545210/.

166. REFERENCES
SURGERY NAME OR LOGO 166
Martin G.S. et al, (2020) Perioperative Quality Initiative (POQI) consensus
statement on fundamental concepts in perioperative fluid management: fluid
responsiveness and venous capacitance. Perioper Med (Lond). 2020; 9:12.
Epub 2020 Apr 21.
Poon SHT, Lee JWY, Ng KM, et al: The current management of acute
uncomplicated appendicitis: Should there be a change in paradigm? A
systematic review of the literatures and analysis of treatment performance.
World J Emerg Surg 12:46, 2017. doi: 10.1186/s13017-017-0157-y.

167. REFERENCES
SURGERY NAME OR LOGO 167
Standard Treatment Guidelines (STG), (2017), Ministry of Health; Ghana
National Drugs Policy (GNDP),7th Edition, Yamens Printing Press, Accra,
Ghana. Pages 630-632.
McKay R., and Shepherd J., (2007) The use of the clinical scoring system by
Alvarado in the decision to perform computed tomography for acute
appendicitis in the ED. AM J Emerg Med.
Jun; 25(5):489-93.PMID: 17543650.

168. REFERENCES
SURGERY NAME OR LOGO 168
Andersson, Manne; Andersson, Roland E. (August 2008). "The appendicitis
inflammatory response score: a tool for the diagnosis of acute appendicitis
that outperforms the Alvarado score". World Journal of Surgery. 32 (8): 1843–
1849. doi:10.1007/s00268-008-9649-y. ISSN 0364-2313. PMID 18553045.
de Castro, S. M. M.; Ünlü, Ç.; Steller, E. Ph.; van Wagensveld, B. A.;
Vrouenraets, B. C. (July 2012). "Evaluation of the Appendicitis Inflammatory
Response Score for Patients with Acute Appendicitis". World Journal of

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Surgery. 36 (7): 1540–1545. doi:10.1007/s00268-0121521-4. ISSN 0364-
2313. PMC 3368113. PMID 22447205.
Kollár, D.; McCartan, D. P.; Bourke, M.; Cross, K. S.; Dowdall, J. (2014-09-
23). "Predicting Acute Appendicitis? A comparison of the Alvarado Score, the
Appendicitis Inflammatory Response Score and Clinical Assessment". World
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170. THANK YOU