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IMS Case 3

IMS Case 3. Personal Details. Name : NF Registration No. : 345104 Age : 14 years . Occupation : Student Race : Malay Religion : Muslim. Pain at the right iliac fossa of the abdomen for the past 10 days. Chief Complaint. History of Presenting Illness.

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IMS Case 3

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  1. IMS Case 3

  2. Personal Details Name : NF Registration No. : 345104 Age : 14 years . Occupation : Student Race : Malay Religion : Muslim

  3. Pain at the right iliac fossa of the abdomen for the past 10 days. Chief Complaint

  4. History of Presenting Illness • The pain was constant. • started at the epigastric region but gradually shifts to the right iliac fossa. • described it as a severe gripping type of pain. • He went to a clinic the next day but the medication which they prescribed did not relieve his condition. • The pain was progressing worse day by day and he was admitted to the hospital on 2nd of April 2009 (last Thursday). • Positive associated symptoms: • diarrhoea of 10 times with yellowish, watery stool on that day, no blood seen. • mild fever, running nose and coughing with green colour sputum No blood seen in the sputum. He said coughing could slightly reduce the pain.

  5. Systemic Review • Cardiovascular System: • Dull, intermittent chest pain, no radiation. No peripheral cyanosis. No palpitation. • Respiratory System: • There was shortness of breath when he cough. • Gastrointestinal system: • Loss of appetite and had lost 1 kg of weight within 10 days. • Urogenital system : • Dysuria with no obstructive symptoms such as weak flow, hesitancy, terminal dribbling or incomplete evacuation. • Normal urination habit

  6. Past Medical History He was admitted to the HTJ before due to high grade fever when he was young. He has no history of asthma, diabetes mellitus or hypertension.

  7. Family History No significant family History

  8. Social History He does not smoke or drink alcohol. He seldom exercises. He stays in the hostel and eats the food prepared by the hostel everyday. None of his friend in the hostel experienced the same symptoms.

  9. Differential Diagnosis • Acute Appendicitis • Intestinal obstruction • Diverticulitis • Acute gastroenteritis

  10. Investigations

  11. Full Blood Count

  12. Renal Profile

  13. Liver Function Test

  14. Physical Examination • He was alert, conscious, communicative, not in obvious pain and not in respiratory distress. • Vital signs: Temperature – 36 °C Pulse Rate – 70beats per minute. Respiratory Rate – 24 breathe per minute. Blood Pressure – 110/75 mmhg

  15. Final Diagnosis • ACUTE APPENCITIS

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