Clinical Insight: Approach to a Surgical Case

History

A 19-year-old man presents with a 2-day history of abdominal pain. The pain started in the central abdomen and has now become constant and has shifted to the right iliac fossa. The patient has vomited twice today and is off his food. His motions were loose today, but there was no associated rectal bleeding.

Examination

The patient has a temperature of 37.8°C and a pulse rate of 110/min. On examination of his abdomen, he has localized tenderness and guarding in the right iliac fossa. Urinalysis is clear.

Blood Investigations show a leukocytosis with a left shift.

These clinical features all point to a diagnosis of Acute Appendicitis.

Features that are suggestive are stylized above.

In such a case, emphasis is on pattern recognition. Amongst all the potential differentials for causes of abdominal pain, one must be aware of and keen towards their varied presentations.

A consistent pain points to an inflammatory process. No bowel symptoms rules out intestinal pathology.

Migratory pain with tenderness + guarding is indicative of Appendicitis. So is vomiting, nausea, anorexia. Also elevated temperature and a high WBC count. Compile your pertinent positives and negatives and rule in or out your differentials with clinical acumen and investigations based on your suspicions. Then treat accordingly.

In this case, an Appendectomy.