Clinical Case - Acute appendicitis
Patient Nina G. 30 years old. Married. Female. Admitted to the hospital on 20th September
2013 morning at around 12.15 p.m with acute severe pain in the right lower quadrant.
Anamnesis Morbi: The abdominal pain started in the umbilical region at around 10 am in
the morning and then shifted to the right lower quadrant. The intensity of pain increased
and she had significant anorexia which was followed by vomiting nearly 2 times, then she
was admitted to the hospital by her husband. She underwent an appendectomy at 2.30 p.m
which took 35 minutes time.
Anamnesis Vitae: She has a surgical history of Caesarean Section on 2009 and delivered a
healthy baby. She does not have any history about any chronic diseases. She has had acute
episodes of viral and bacterial infections with the seasonal changes, which was not
prolonged more than 3-5 days.
Allergic anamneses for any drugs are negative. Gynaecological diseases or infections are
negative. In childhood she had suffered from measles. She has a family history of
cardiovascular diseases according to her father died with a MI (myocardial infection) and
had chronic hypercholesterolemia.
Person Assessment: During person assessment at the time of hospitalisation she showed
sub febrile fever of 37 C. Anorexia. Pain in the right lower quadrant of the abdomen while
palpation and the rigidity of the abdomen in the same area.
Diagnostic Procedure: FBC – leucosytosis and elevated ESR; Urinanalysis – Normal;
Ultrasound – Shows enlargement of appendix, and increased thickness of the mural wall,
Periappendiceal fluid, distended lumen of appendix; Laparoscopy – Hyperaemia of
appendix, increased in size and periappendiceal fluid.
Diagnosis: Acute appendicitis.
Treatment: Appendectomy – Removal of the appendix.
Status Praesens: At the time of shift her condition satisfactory, conscious, responsive and
vital signs are satisfactory (temperature: 36.6 C, Pulse rate: 67 bpm, Respiratory rate: 16
cpm, BP: 100/80 mmHg.
Note that in differential diagnosis of appendicitis in women we should check for
gynaecological diseases in women because some diseases of the ovary can show the
same clinical signs of appendicitis.