ANATOMY ABDOMEN
Case 1 : Acute Appendicitis
40 ear old malay male, Ex smoker 2 years ago, NKMI
Presented with generalized abdominal pain since 5 pm yesterday.
Sudden onset
Continuous in nature
Non radiated
Vomiting x 2 : food and fluid, no blood.
No altered bowel habit - no constipation/ no diarrhea
No constitutional sx - no LOA/LOW
No UTI sx
H/o eating ouside food - night market
No family h/o malignancy
O/e alert concious, pink, not septic looking, good PV, crt <2s
Bp stable, not tacycardic
P/A soft, no guarding, tender at Right Iliac Fossa, Rebound tenderness positive, Rovsing sign positive, renal punch negative.
Renal punch negative
PR empty rectum, prostat not enlarged, no mass palpable
Hb 14 TWC 14 PLT 300
RFT/LFT normal
Amylase Normal
Impression - Acute Appendicitis
Plan
1. Knbm with 4 pint IVD - 2 pint Normal Saline, 2 pint Dextrose 5% over 24 Hour (if pt DM might consider 4 pint all Normal Saline)
2. To post case - Laparoscopic Appendicectomy KIV open
3. For consent
4. Confirm GSH
5. Start IV Cefobid 2g stat then 1g BD
+ IV Flagyl 500mg stat then TDS
6. Start IV Tramal 50mg TDS
Case 2 - Liver Abcess
HEPATOBILIARY ANATOMY
40 year old malay male,
U/L DM
Presented with history with right upper quadrant pain, radiated to the lower back pain, continous in nature for 1 week, worsening by movement, had vomiting on the day one off illness 2 times, nauseated, loss of appetite for 1/52.
H/o went on off to jungle (tanam pokok getah), watersource at home (well), no altered bowel habit. Claimed concentrated urine (tea colored) and pale color stool, no h/o malignancy. Last BO today morning. H/o take traditional medication/analgesic
Raised direct bilirubin
Raised transaminases 100++
Raised ALP 400++
Amylase 20
TWC 30, Hb 14, Platelet 300
Febrile, tacycardia, BP stable, not tacypnic
P/A : mild distended, murphy sign positive, liver 3 FB palpable, gallbladder not palpable, mild tender at RUQ
ECQ - no ischemic changes.
AXR - No dilated bowel, no air under diaphragm.
Ufeme - All less than 10
Plan
1. KNBM with 4 pint (2 pint NS, 2 pint D5%)
2. For CT HBS cm
3. To take urine diasthase/leptospira serology/meliodosis/malaria
4. Start IV Cefobid 2g stat 1g BD / IV Flagyl 500mg
Treat as acute cholangitis, TRO causes of obstructive jaundice.
Ddx
- Acute Cholangitis
- Choledocholithiasis
- Cholecystitis
- Dengue
- Leptospirosis
- Malaria
- Pancreatitis
- Liver abcess
Done USG HBS
- Liver Abcess 8cm x 5cm x 6 cm
- Distended gallbladder, unable tro stone.
Plan
1. To request USG guided drainage cm under IR if amendable, kiv for CT Liver 4 phase.
2. Increase IV Flagyl to 1g TDS
3. NBM at 2 am with 4 pint NS (2 pint NS, 2 pint D5%)
Notes :
📌Spread abcess possible from where?
- Hematological spread, direct contact (eg psoas abcess)
📌Causes?
- Ameobic abcess
- Thyphoid
- Streptococcus
- Meliodosis
Case 3 : Intestinal Obstruction
45 yo malay male. No known Medical Illness. Chronic smoker since 20 year ago.
P/W abdominal distension
Asoc with abd pain, colicky in nature, pain score 5/10, vomiting x 4, fluid content, no blood. Last BO 2 day ago, minimal stool, not passed flatus today. H/o altered bowel habit since 3/12, tenesmus 1/12. No blood, no mucus. Had Constitutional Sx - LOA, loosen cloth. Unable to quantify LOW.
No h/o malignancy in family, no fever, no UTI/URTI sx
O/e alert concious pink, BP stable, not tacycardia, afebrile.
AXR : dilated small bowel
CXR : No air under diagphram (tro perforated bowel)
Ix : FBC/ ABG (lactate), RFT,LFT, Mg
Plan
1. Nil By Mouth (NBM)
2. IV Drip 4 Pint (2 pint Normal Saline, 2 Pint D5%)
3. Strict Input Output Chart (strict I/O chart - aim urine output 0.5 - 1 cc/kg/H)
4. Cont Vital Sign Monitoring
- Keep MAP >65, SBP > 100mmHg
- To inform if patient tacycardic HR >90 bpm
5. Keep pt on Nasal Prong 3L/min
6. Start IV Tramal 50mg Stat and TDS
7. Start IV Cefobid 2g stat then 1g BD, IV Flagyl 500mg stat then TDS
8. Start IV Pantoprazole 40mg BD
9. For CT Abdomen Urgent coming morning
10. Ryles Tube free flow and 4 hourly aspirate
