Download MBBS (Bachelor of Medicine and Bachelor of Surgery) Surgery Final Year Case Presentation Mass Surgery Clinical Examination Discussion and Treatment
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Thirumalai
13 year old boy
studying 7th std
coming from Ponneri,
belonging to socio economic class IV
came to the OP
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-2_1.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-2_2.jpg)
CHIEF COMPLAINTS
Pain in the right lower abdomen for
past 4 days
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-3_1.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-3_2.jpg)
PRESENTING ILLNESS
The patient was apparently normal 4 days
back after which he developed
pain : in right lower abdomen
for 4 days,acute in onset
colicky in character
intermittent in nature with
symptomless interval,started in the umbilical
region and progressed towards right iliac fossa
moderate to severe intensity
aggravated by coughing and relieved
by rest.
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-4_1.jpg)
H/O Vomiting: for 3 days
3-4 episodes/day-immediately
after eating
contains food particles
non projectile,not bile
stained,not blood stained,not foul smelling
relieved by antiemetics
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-5_1.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-5_2.jpg)
H/O FEVER: for past 3 days,
sudden in onset,
low grade fever,continuous,
not associated with chills and
rigors,
no h/o evening rise of
temperature,
not associated with night
sweats,convulsions,altered sensorium,
relieved by medication.
He is currently afebrile
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-6_1.jpg)
H/O loss of appetite for past 3 days
No H/O cough with expectoration
No H/O Loss of weight
No H/O Abdominal distension
No H/O Constipation, Diarrhoea
No H/O Bleeding per rectum, blood in stools
No H/O Painful, increased frequency of
urination, hematuria
No H/O Jaundice, bone pain
No H/O headache,blurring of vision
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-7_1.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-7_2.jpg)
PAST HISTORY
No H/O similar complaints in the past
No H/O Diabetes mellitus, Hypertension,
Bronchial asthma, Epilepsy,jaundice
NO H/O previous surgery and hospitalisation
No H/O Blood transfusion
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-8_1.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-8_2.jpg)
PERSONAL HISTORY
Consumes non vegetarian diet
Non smoker,not an alcoholic
Normal bowel and bladder habits
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-9_1.jpg)
ALLERGIC HISTORY:
No H/O Allergy to drugs or food.
FAMILY HISTORY:
No significant family history
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-10_1.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-10_2.jpg)
GENERAL EXAMINATION
Patient is conscious, oriented,
Moderately built and nourished
No Pallor
No icterus
No cyanosis
No Clubbing
No pedal edema
No generalized lymphadenopathy
Hydration:fair
Afebrile
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-11_1.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-11_2.jpg)
VITALS
Pulse rate: 86/min, regular in rhythm,
normal in volume, no specific character, no
radio-radial or radio-femoral delay, felt in
all palpable peripheral vessels
Respiratory rate: 18/min,abdomino
thoracic
Blood pressure: 110/70 mm Hg, in right
upper arm in sitting posture
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-12_1.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-12_2.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-12_3.jpg)
LOCAL EXAMINATION OF
ABDOMEN
After getting consent from patient and
explaining procedure to patient,he is exposed
from nipples to mid thigh,and examined on
both sides under bright light in supine
position with male attender by the side.
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-13_1.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-13_2.jpg)
ABDOMEN EXAMINATION
INSPECTION:
Abdomen ? Normal in shape, umbilicus in
midline and inverted
All quadrants move equally with respiration
No scar, sinus, dilated veins, visible pulsation
No fullness, visible gastric/intestinal
peristalsis
Flanks free, hernial orifices free, external
genitalia normal
Renal angle free
Left supraclavicular fossa- normal
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-14_1.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-14_2.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-14_3.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-14_4.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-14_5.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-14_6.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-14_7.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-14_8.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-14_9.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-14_10.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-14_11.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-14_12.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-14_13.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-14_14.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-14_15.jpg)
PALPATION
Patient in supine position with hips and knees
semi flexed
Not warm, tenderness at McBurney's point,
guarding present
A mass is felt in the right iliac fossa of size 3*3
cm, hemispherical in shape
Extends-medially 2cm from umbilicus
laterally 3cm from anterior superior
iliac spine
superiorly 5cm from right costal margin
at midclavicular line
inferiorly 4cm from pubic symphysis
Firm in consistency, with irregular surface,with ill
defined borders,immobile,no pulsation,normal
skin
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-15_1.jpg)
No organomegaly
Left supraclavicular region -no nodes
palpable
Hernial orifices- free
External genitalia-normal
Carnett's test-negative
Renal angle ?no tenderness
Per rectal examination to be done
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-16_1.jpg)
PERCUSSION:
Impaired resonance over the mass
other quadrants-tympanic
resonance
Liver span ? normal
AUSCULTATION:
Normal bowel sounds heard
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-17_1.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-17_2.jpg)
OTHER SYSTEM EXAMINATION
CVS- S1, S2 heard, no murmur
RS- Normal vesicular breath sounds heard
CNS- No focal neurological deficit
SPINE and CRANIUM-normal
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-18_1.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-18_2.jpg)
DIAGNOSIS
A case of Right iliac fossa mass probably
Appendicular mass.
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-19_1.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-19_2.jpg)
INVESTIGATIONS
Baseline :
Blood inv- Hemoglobin, Total count,
Differential count, ESR, Blood grouping and
typing
Blood sugar, Urea, Serum creatinine,
Electrolytes
Urine- albumin, sugar, deposits
Stool- occult blood
Xray Chest, ECG
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-20_1.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-20_2.jpg)
SPECIFIC INVESTIGATIONS
Ultrasound abdomen
Xray abdomen erect
CT scan abdomen
Mantoux, Sputum for acid fast bacilli
Tumour markers- CEA, Alpha fetoprotein
Colonoscopy
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-21_1.jpg)
![](4e70823d-c89f-4cbd-aff9-ef7b16b4c0c3-21_2.jpg)
TREATMENT
APPENDICULAR MASS:
1. Ochsner and Sherren regimen
A-aspiration with ryles tube
B-bowel care(do not give purgatives)
C-charts
D-drugs
E-exploratory laparotomy not to be done
F-fluids(nil oral for few days)
2.interval appendicectomy after 6 weeks
This post was last modified on 08 August 2021