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CASE PRESENTATION ON APPENDICITIS I Introduction Appendicitis is the most common cause of acute abdomen in the United States, is the

e most common reason for emergency abdominal surgery. Although it can occur at any age, it more commonly occurs between the ages 10 and 30 years. II - Objectives: General: Specific: III Definition It is the inflammation of the vermiform appendix, usually acute, that if undiagnosed leads rapidly to perforation and peritonitis. Causes: basically idiopathic (unknown) a hard mass of feces (fecalith) foreign body in a lumen of the appendix fibrous disease of the bowel wall an adhesion or a parasitic quadrant stricture of the bowel lumen barium ingestion viral infection

IV. Patients Profile A. General Data Patient name: Address: Age: Weight: Gender: Birthday: Pt. C Jaen, Nueva Ecija 12 y/o 21 kilograms Male August 28, 1997

Nationality: B. Chief Complaint

Filipino

Persistent abdominal pain accompanied by nausea and vomiting (7 times) 2 days PTA C. History of Present Illness Two day prior admission, patient experience persistent abdominal pain, generalized during the first day then becomes localized in the right lower quadrant. Patient wasnt able to consume food on the second day due to persistent nausea and vomiting. Emergency appendectomy was done within the day of admission. D. Past Health History 1. Past Illnesses: Measles, Influenza (never hospitalize before) 2. Current Medication: Calpol, Neo-kidilets, Ceelin 3. Allergy: no allergies stated E. Heredo-Familial Illness Paternal: +DM Maternal: no illness stated F. Personal/ Social History A. Habits: Able to consume meals in less than 5 minutes B. Caffeine: Never coffee, but drinks Milo or Ovaltine in the morning C. Smoking: Never smoke D. Alcohol: Never drinks E. Drugs: Calpol, Neo-kidilets, Ceelin, Biogesic, Neozep F. Lifestyle: Active/ Playful G. Rank in the Family: 3rd of 4 children H. Educational Attainment: High School Level G. Environment The family does not totally belong to the poverty line. They provide developmental support for their children and they live near the city.

V.

I. Physical Assessment A. General Survey Patient is awake, alert, verbally responsive and oriented to the environment and still with the complaint of RUQ pain associated with intermittent nausea and vomiting B. Admitting vital signs: T- 37.5C P-89bpm R-24cpm BP-130/90 mmHg C. General Assessment - weak - pain scale of 7 - conscious but seems confusion D. Regional Examination Body Parts 1. Skin Techniques *Inspection Actual findings (-) Jaundice No abrasion and lesion Normal Findings Skin color varies from light to deep abrasion and lesion Analysis The skin color is light brown; there abrasion visible. Height: 49 inches Weight: 21 kgs

brown, absence of is no lesions and

* Palpation

No edema Skin turgor was slightly altered

No edema Good skin turgor

There is poor skin turgor due to vomiting that result in dehydration. Normal

2. Eyes

*Inspection

Yellowish sclera PERRLA Conjunctiva is slightly pale and dry.

White sclera PERRLA Pinkish conjunctiva, slightly moist

Paleness of conjunctiva due to fluid deficit.

3.Lips

*Inspection

Slightly dry and cracked

Moist and not cracked Rounded abdomen No lesion No tenderness No palpable mass

Dryness of membranes due to fluid deficit Normal

4. Abdomen

*Inspection

Rounded abdomen No lesion

* Palpation

(+) rebound tenderness (-) Rovsing sign noted.

Rebound tenderness was due to inflammation of the appendix. Rovsings sign was noted to be negative because upon palpating the lower left quadrant, there is no pain felt in right lower quadrant.

E. Activities of Daily Living Gordons Functional Pattern Function Pattern 1. Health perception and health management Before Hospitalization Patient is not health conscious. After Hospitalization Listen to the physicians instruction and somehow able to attain better perception of his health. 2. Nutrition and Metabolic Have 3 meals every day, tend to eat fast due to active lifestyle. Eat meal 3x a day Food was regulated according to the Because of hospitalization diet was modified Analysis He become aware that he is responsible for his health.

3.Elimination

Bowel movement was not evident for the past three days.

doctors order. Bowel movement was also not evident immediately after surgery. 12 hours prior transfer to ward, (+) bowel movement was noted. Sedentary; needs to lie down at bed, but ambulation was encouraged.

Constipation prior admission was due to inflammation of the appendix, surgery temporary decrease GI peristalsis. Patient understands the limitations and restrictions of activities, and importance of early ambulation. Health teaching helps the client to understand his condition

4. Activity-Exercise

Active lifestyle

5. Cognitiveperceptual

Patient has lack of knowledge about his current condition

Patient understands the disease and he was accepting information from the health care provider for his own good. Usually sleep length was 6 hours, and was able to take naps throughout the day. Patient self-esteem becomes low due to belief that he is not complete anymore. Patient relationship with his family and friends becomes more intact. Patient is not sexually active. Felt secure that he will get healthy soon.

6. Sleep-Rest

Patient was able to sleep 6 8 hours at night. Never had afternoon naps. Patient has high selfesteem

Patient sleep pattern is disturbed due to the operation that he undergone. He became anxious because he thinks that he cannot perform his best in any activities. Hospitalization brought the family and his friends to him. Hospitalization doesnt change his sexuality and reproduction state. Hospitalization improves the coping

7. Self-perception and self-concept

8. Role- relationships

Patient has a good relationship with his family and friends.

9. SexualityReproductive 10. Coping-Stress tolerance

Patient is not sexually active. Puberty was just setting in. He was afraid that his condition will worsen.

mechanisms of the 11. Values-Belief Patient is a Roman catholic. He go to church with his parents. Patient spiritual belief becomes high. He always pray and promise to go to church every Sunday VI. Anatomy and Physiology patient. Patient becomes GOD lover because of what happened to him.

VII.

Pathophysiology

VIII.

Management

I. Medical Management

II. Surgical Management Operation: Surgeon: Time/Date: Pre-Op Dx: Post-Op Dx: Specimen: Complications Cholecystitis Empyema of the gallbladder Pancreatitis

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