Indexing Title: RJOSON’s Medical Anecdotal Report [04-8]

MAR Title: Clinical Monitoring Scheme for Appendicitis, Absence of Laboratory Examinations, and Minimal Operating Expense

Date of Medical Observation: November 22, 2004

Narration:

JL, a 50-year-old male, a brother-in-law of mine, came all the way from Pangasinan to my house to consult me for possible acute appendicitis.  He arrived in my house at 11:30 pm of November 22, 2004.  After initial examination, my primary diagnosis was gastroenteritis and my secondary diagnosis was acute appendicitis.  He had a strong history of loose bowel movement 4 days prior and except for direct tenderness on the right lower quadrant, there was no guarding.  Since he was told that he had acute appendicitis by a provincial doctor, he kept on asking me whether he really had it.  At that point in time, I cannot completely rule it out.  I decided to keep on asking him on the details of the history, especially, the onset of abdominal pain, the type of pain, and chronology of events.  I also decided to keep on palpating his abdomen.  It took me about 30 minutes to finally decide that I should operate on him with a primary diagnosis of acute appendicitis.  My bases were a definite and persistent right lower quadrant abdominal pain even in the absence of guarding and fever and even in the presence of loose bowel movement.

He asked me whether he needed to have some examinations done.  I said no need.  Thus, I instructed him to go to Manila Doctors Hospital at 1:00 am and scheduled him for right lower quadrant exploration and appendectomy. 

On opening, there was no exudate to suggest peritonitis.  I initially thought I was wrong in my evaluation.  I then looked for the appendix.  I initially had a hard time locating it. After enlarging the incision, I finally saw it, located retroileally, near the pelvis and adherent to the retroperitoneal lining.  The distal third of the appendix was bulbous and minimal fibrin.  At this point, I was glad to discover that I was correct in deciding to operate afterall.

Insights (Discovery, STIMULUS, REINFORCEMENT) / (Physical, Psychosocial, ETHICAL):

Time and again, the clinical monitoring scheme that is being used by me and the surgical residents of the Department of Surgery of Ospital ng Maynila Medical Center has proven to be useful.  It is the most cost-effective and reliable paraclinical diagnostic procedure for acute appendicitis. 

Time and again, too, selective use of laboratory examinations goes for patient’s comfort and minimization of expenses.  My brother-in-law was operated on with no laboratory examination, no antibiotics, just 3 liters of intravenous fluids, few tablets of paracetamol, and two-day confinement.