Sir William Osler, A Canadian Physician once said ; “He
who studies medicine without books sails an uncharted sea, but he who studies
medicine without patients does not go to sea at all.”
From my understanding, seeing a patient without
prior knowledge is indeed a BIG NO. While anything could happen, you will not be
able to formulate a diagnosis by just relying on symptoms that has being described in the
textbook. Patient will never always come with
100% classical description from the textbook. However, the magic word “COMMON
IS COMMON” will sometime be very useful. Only by seing more and more patient
and do a lot of observation than you can be more accurate in making diagnosis. In another context , having a prior knowledge without seeing a patient will bring
you nowhere in the room of improvement.
I have experienced three cases of appendicitis with
different presentation and spectrum of severity. Even though appendicitis is a
very straight forward case. But in certain case, the classical symptoms may not
appear at all. The classic history of anorexia and periumbilical pain followed
by nausea, right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of
cases (eMedicine article 773895)
Alvarado score using in the aid of making diagnosis
in district hospital or clinic setting may also yield a low score but patient
did actually have appendicitis.
First patient is a late 20 year old man presented
with sudden onset left flank pain that radiates to the groin that awaken him
from sleep. The pain score is 7/10 and does not relief with any measures. The
history that i obtain more suggestive of pyelonephritis. Recent history of
sexual intercourse with urinary tract infection symptoms and positive renal
punch kind of deviate me from the real diagnosis. Furthermore, the classical
Rovsing, Psoas and Obturator signs are all negative. The only thing is that
patient having a generalized peritonitis and slightly involuntary guarding over
the right lower quadrant region. Total white blood cells are just mildly
elevated and other blood investigations are normal. Urine FEME did not suggest
a urinary tract infection. In view of the sudden onset of pain and the physical
examination, my specialist decided that it is a perforated appendicitis and
intra operatively, it is a valid diagnosis.
A Second patient who is a 30 year old gentleman presented with history of poorly
localized lower abdominal pain but more on the right side. It is associated
with 15 episodes of vomiting and constipation. Abdomen is distended and the patient
was treated as sub acute Intestinal obstruction in the emergency department.
There was no fever, migratory pain, rebound tenderness, and clinical tests for
appendicitis are negative. After a suppositories enema and pain management,
patient was discharged home. A month later he come in with a similar
presentation except without vomiting and was managed the same. However, the
pain subsided for one day only. Later, he develop sudden onset severe right
iliac fossa pain while walking from the toilet. The pain score is about 7-8/10.
There was nausea but no vomiting, loss of appetite, migratory pain, fever.
Examination shows right hypochondriac pain on deep palpation. Rovsing, Psoas
and Obturator signs are negative. In ward, fever was documented, total white
blood cells was elevated. Patient was posted for appendicectomy.
Intraoperatively, there was a perforated appendix with localized pus and lot of
adhesion. Therefore, a diagnosis of acute on chronic appendicitis was made.
Third patient is an 11 year old boy who presented
with 10 days history of nausea and vomiting with diarrhea and was treated as
Acute Gastroenteritis. Upon presentation to us, the child was very ill with
septic looking. There was a generalized peritonitis and tender left inguinal
mass which was non reducible, well defined margin and does not increase in size
with cough reflex. Both testis are palpable and associated with hydrocele of
the right testis. A diagnosis of strangulated hernia was made and patient was
posted for emergency herniotomy, KIV laparotomy. However, intraoperatively, it
was noted that the swelling was actually a pus collection that extend to the
scrotum. There was no obstructed bowel or real hernia sac and therefore midline
incision was done. The abdomen was filled with 1 Litre of pus and the appendix
was noted perforated. Therefore a diagnosis of intraabdominal sepsis secondary to
perforated appendix was made. He made a good recovery except developing wound
breakdown at the incision site which was later resolve with daily dressing.
From the three cases, I learn that a previously low
score abdominal pain that suddenly become worsen should alert a physician that
organ perforation may be occurs and should consider appendicitis as an
aetiology since it is a common condition. Secondly, in children, acute
appendicitis may present with acute gastroenteritis symptoms and if it is non
resolving, therefore it should be investigate more. Failure to diagnose acute
appendicitis or perforated appendicitis will increase the morbidity and
mortality of a patient.
