Download MBBS Final Year Surgery Case Presentation Mass Surgery Clinical Examination Discussion and Treatment

FirstRanker.com

Thirumalai

• 13 year old boy

--- Content provided by‍ FirstRanker.com ---

• studying 7th std
• coming from Ponneri,
• belonging to socio economic class IV came to the OP

CHIEF COMPLAINTS

• Pain in the right lower abdomen for past 4 days

--- Content provided by​ FirstRanker.com ---

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.

• 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

• 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.

--- Content provided by‌ FirstRanker.com ---

• He is currently afebrile

• 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

--- Content provided by⁠ FirstRanker.com ---

• 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

--- Content provided by‍ FirstRanker.com ---

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

--- Content provided by⁠ FirstRanker.com ---

PERSONAL HISTORY

• Consumes non vegetarian diet
• Non smoker, not an alcoholic
• Normal bowel and bladder habits

ALLERGIC HISTORY:

--- Content provided by‍ FirstRanker.com ---

• No H/O Allergy to drugs or food.

FAMILY HISTORY:

• No significant family history

GENERAL EXAMINATION

• Patient is conscious, oriented,

--- Content provided by‌ FirstRanker.com ---

• Moderately built and nourished
• No Pallor
• No icterus
• No cyanosis
• No Clubbing

--- Content provided by​ FirstRanker.com ---

• No pedal edema
• No generalized lymphadenopathy
• Hydration: fair
• Afebrile

VITALS

--- Content provided by‍ FirstRanker.com ---

• 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

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.

--- Content provided by​ FirstRanker.com ---

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

--- Content provided by‌ FirstRanker.com ---

• No fullness, visible gastric/intestinal peristalsis
• Flanks free, hernial orifices free, external genitalia normal
• Renal angle free
• Left supraclavicular fossa- normal

FirstRanker

--- Content provided by⁠ FirstRanker.com ---

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

--- Content provided by FirstRanker.com ---

• Firm in consistency, with irregular surface, with ill defined borders, immobile, no pulsation, normal skin

• No organomegaly
• Left supraclavicular region -no nodes palpable
• Hernial orifices- free
• External genitalia-normal

--- Content provided by⁠ FirstRanker.com ---

• Carnett's test-negative
• Renal angle -no tenderness
• Per rectal examination to be done

• PERCUSSION:
• Impaired resonance over the mass, other quadrants-tympanic resonance

--- Content provided by​ FirstRanker.com ---

• Liver span – normal
• AUSCULTATION:
• Normal bowel sounds heard

OTHER SYSTEM EXAMINATION

• CVS- S1, S2 heard, no murmur

--- Content provided by⁠ FirstRanker.com ---

• RS- Normal vesicular breath sounds heard
• CNS- No focal neurological deficit
• SPINE and CRANIUM-normal

DIAGNOSIS

• A case of Right iliac fossa mass probably Appendicular mass.

--- Content provided by‌ FirstRanker.com ---

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

--- Content provided by FirstRanker.com ---

• Xray Chest, ECG

SPECIFIC INVESTIGATIONS

• Ultrasound abdomen
• Xray abdomen erect
• CT scan abdomen

--- Content provided by‌ FirstRanker.com ---

• Mantoux, Sputum for acid fast bacilli
• Tumour markers- CEA, Alpha fetoprotein
• Colonoscopy

TREATMENT

APPENDICULAR MASS:

--- Content provided by​ FirstRanker.com ---

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

   --- Content provided by FirstRanker.com ---

   • F-fluids(nil oral for few days)
2. interval appendicectomy after 6 weeks