case report mitral valve prolapse

8/12/2019 Case Report Mitral Valve Prolapse

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General Data:

Allan macapagal, 37 y/o, married, Roman Catholic, works as a welder in Manila, fromArayat Pampanga.

Source and Reliability: The patient himself. Seems Reliable (90%)

Chief Complaint:

Epigastric pain.

History of present illness:

On Oct 22nd, 10 AM, he experienced remitting epigastric pain of pain scale 5/10 (10being the most severe pain the patient has ever experienced), that later generalizedstarting from suprapubic radiating to upward. There were no associated vomiting, fever

or body malaise. He thought it will just go off by sometime and continued working. Hedid not get any rest.

At 5:30 PM, the pain still persisted of pain scale 7/10. The pain continued with vomiting.He tried drinking water (hot and then cold) but afforded no relief. He started feelingnumbness on the extremities also. He tried resting for a while but still not relieved.

At 9:30 pm, he was admitted at the V Luna Hospital in Manila because of the severepain scale of 10/10. Laboratory tests were done and he was diagnosed with acuteappendicitis. He was told that he needs emergency operation but he requested fortransfer to his home town because his relatives were here only. He was given a referralslip and was transferred and admitted to JBLMRH at 1 am oct 23rd and was scheduledfor operation.

Past Medical History:

Childhood illnesses and immunization status: He had childhood illnesses likechickenpox and measles. He had complete childhood immunizations

Allergies: The patient does not have any known allergies to drugs or food.

Medical: He does not have any known illness or co morbidities such ashypertension, cancer, thyroid problems, tuberculosis, asthma or diabetes. He is nottaking any maintenance drugs.

Surgical: None

Previous hospitalization: 17 years ago due to accident in Quezon province.

Psychiatric: None

ACUTE APPENDICITIS DATE: 30TH OCT. 2012

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Time of interview: 1-5 PMDate of interview: 23rd Oct.12


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Family History:

His father is 63 years old and diabetic and mother is 58 years old and is healthy. Thepatient has 9 other siblings. He has 4 siblings, all of them are healthy.

Personal and Social History:

The patient currently works as a welder in Manila. He completed high school. Hesmokes 12-15 sticks per day for 12 years. He drinks alcoholic beverages thrice a week.He has a stable financial condition. He doesnt take any supplements and doesnt takecoffee also. He drinks soft drinks. The source of water is from the faucet. His form ofrelaxation is watching TV. He sleeps for 7 hours a day.

Environmental History:

He lives in a concrete building has 2 floors. The rooms are well ventilated and well lit.

There are 8 people residing there including his cousins and coworkers. The garbage iscollected twice a week.

Diet History:

He takes a mixed type of diet and eats three times a day. He gets his food from themarket and drinks distilled water.

Review of Systems:

General: The patient denies of weight loss or gain, fever, chills or loss of appetite.Skin:No jaundice, no rashes, no lumps, no sores, no itching, no dryness and no changein hair & nails.

Head, Eyes, Ears, Nose, Throat (HEENT):

Head: He denies of headache, dizziness and lightheadedness.

Eyes: No pain, eye irritation and blurring of vision, no excessive tearing, no flashes oflight.

Ears: No hearing loss. No tinnitus, vertigo, infections.

Nose: No nose bleeds, sinus trouble, no nasal stuffiness.

Throat (or mouth and pharynx): No gum bleeding, no sore throat, no difficulty onswallowing.

Neck: He has pain on the anterior neck region. No swollen glands, No stiffness

Respiratory: No cough, wheezing, dyspnea.

Cardiovascular: No orthopnea and palpitations, no chest pains, no edema.


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Gastrointestinal: No indigestion, heartburn. Generalized abdominal pain. No diarrhea,constipation.

Urinary: Urine is light yellow, no frequency/urgency in urination, no dysuria, no grosshematuria and no nocturia.

Genital: No pain, sores, discharge and rashesPeripheral Vascular: No cramps and intermittent claudication.

Musculoskeletal: No joint stiffness, and muscle pain but numbness in the extremities.

Psychiatric: No history of depression or treatment for psychiatric disorders. Nonervousness and suicidal attempts.

Neurologic: No fainting, seizures, motor or sensory loss.

Hematologic: No easy bleeding and bruising, not anemic.

Endocrine: No or cold intolerance, excessive thirst, hunger and polyuria. Sweatsaveragely.

Physical Examinations:

General Survey:

On interview, the patient is conscious, coherent, appropriate and ambulatory. He issthenic, not in respiratory distress and well oriented to time, person and place. He alsohas a guarding behavior on his abdomen

Vital Signs:

BP:110/80 mmHg PR:67 bpm RR:19 cpm Temp:37.1C (Right axilla)Skin, Hair and Nails:

Patient has brown skin, no jaundice, cyanosis noted. There were also no edema,contractures or lesions seen. He has a good skin turgor; return within few seconds uponskin pinching in the forehand. Patient has black hair. The nails were dirty and there wereno clubbing or koilonychias noted.

HEENT:

Head:

Grossly the head is symmetrical to body. There were no scars, lesions, masses oralopecia present. There was no deviation of the jaw from the midline upon opening ofthe mouth. Good quality of temporal pulse was noted with no area of tendernessthroughout the cranium and facial areas upon palpation.


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Eyes:

Patient has anicteric sclerae without any swelling, paleness, cataracts, excessivetearing, discharge upon inspection. The eyebrows and eyelashes are evenly distributed.Pupils were equally round and reactive to light and accommodation. With positive directreflex and consensual light reactions. Pupil size is 2-3 mm. Extraocular movement in all

direction and peripheral vision were intact.

Ears:

There is no redness, swelling, masses, deformities or discharge upon inspection of theears; positive cone of light. The patient has pearly white intact tympanic membrane.There was no tragal, auricular or mastoid tenderness upon palpation.

Nose and Sinuses:

Grossly, the nose and nasal septum are located midline with symmetrical external nasalstructures There were no observed external deformities, masses or lesions. There wereno complaint of tenderness and pain upon palpation.

Mouth and Pharynx:

The lips, gum, teeth, tongue and floor of the mouth do not have lesions. There is nobleeding nor any deviations. There is positive protrusion and retraction of the tongue.

Neck and Thyroid Gland:There was no cervical lymphadenopathy. The thyroid gland is not palpable uponswallowing. Carotid pulse was of good quality without carotid bruit upon auscultation.

Chest and Lungs:

Thorax is symmetrical without any deformities, chest retraction or local lag in therespiratory movement; no masses and lesions present. There were no areas oftenderness noted. Tactile fremitus and sounds are transmitted on an equal intensity onboth sides. Areas of the lungs are resonant on percussion. Normal clear breath soundswere heard upon auscultation of both lung fields.

Cardiovascular:

There is adynamic precordium. The point of maximal impulse at the 5th intercostalspace left midclavicular line. Good S1 and S2 without any S3, S4 or cardiac murmursupon auscultation. Regular Rhythm. There are no lifts, thrills and heaves. Radial,brachial and dorsalis pedis pulses are full and equal. No cyanosis or edema.


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Abdomen:

Inspection: The abdomen of the patient was flat, symmetrical and not distended. Therewere no visible peristalses nor visible pulsations.

Auscultation: Bowel sounds were hypoactive. No bruits or friction rub

Percussion: The abdomen was tympanitic on all 4 quadrants.Palpation: There were no masses palpated. The spleen was not palpable. No abdominalpain. Liver span is 8cm. There was rebound tenderness and was positive for Rovsings,psoas and obturator sign. The liver edge was firm, non-tender and non-nodular.

Genito-Urinary:

Kidneys were not palpable and there was no CVA tenderness.

Musculoskeletal/extremities:There were no joint deformities. Good range of motion in hands, wrists, elbows,shoulders, spine, hips, knees, ankles. There were no limitations in extension of theextremities. 5/5 muscular strength on the left and right arm and lower extremities.

Peripheral Vascular:No cyanosis. There were no trace edema or varicosities seen upon inspection of thelower extremities. There was good quality of brachial, ulnar and radial pulses as well asthe popliteal, posterior tibial and dorsalis pedis pulses. Pulses were brisk or normal withsame intensity on both right and left extremities. Good capillary refill time (


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VII intact, able to do facial expression

VIII gross intact hearing, able to lateralize sound and air greater than boneconduction, no nystagmus,

IX, X Gag reflex not examine, uvula at midline

XI intact, able to raise shoulderXII tongue in midline, able to do phonation and protrusion of the tongue

Salient Features:

Subjective:

37yearold male, with abdominal pain that started at the supra pubic area and wasgeneralized later for last 28 hours. Associated with vomiting.

Objective:

Abdomen with tenderness and was positive for Rovsings, psoas and obturator sign.Patient is conscious.

Differential Diagnoses:

Diverticulitis:

Rule In Rule Out

Abdominal Pain first started at supra pubicarea.

Pain is not present for several days priorto presentation.

Accompanied by anorexia, nausea, andvomiting

No altered bowel habits, especiallyconstipation, is seen in the patient

Peptic Ulcer Disease

Rule In Rule Out

Epigastric pain No bleeding, hematemesis or melena

Alcoholic and smoker No relation of pain with the intake offoods.


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Acute Appendicitis

Rule In

Started with epigastric pain, followed byvomitting

Positive for rosvings, psoas and obturator

signs.

Final Diagnosis:

Acute Appendicitis

EpidemiologyAppendicitis is one of the more common surgical emergencies, and it is one of the mostcommon causes of abdominal pain. In the United States, 250,000 cases of appendicitisare reported annually, representing 1 million patient-days of admission. The incidence ofacute appendicitis has been declining steadily since the late 1940s, and the currentannual incidence is 10 cases per 100,000 population. Appendicitis occurs in 7% of theUS population, with an incidence of 1.1 cases per 1000 people per year. Some familialpredisposition exists.

In Asian and African countries, the incidence of acute appendicitis is probably lowerbecause of the dietary habits of the inhabitants of these geographic areas. The

incidence of appendicitis is lower in cultures with a higher intake of dietary fiber. Dietaryfiber is thought to decrease the viscosity of feces, decrease bowel transit time, anddiscourage formation of fecaliths, which predispose individuals to obstructions of theappendiceal lumen.

In the last few years, a decrease in frequency of appendicitis in Western countries hasbeen reported, which may be related to changes in dietary fiber intake. In fact, thehigher incidence of appendicitis is believed to be related to poor fiber intake in suchcountries.

There is a slight male preponderance of 3:2 in teenagers and young adults; in adults,the incidence of appendicitis is approximately 1.4 times greater in men than in women.

The incidence of primary appendectomy is approximately equal in both sexes.The incidence of appendicitis gradually rises from birth, peaks in the late teen years,and gradually declines in the geriatric years. The mean age when appendicitis occurs inthe pediatric population is 6-10 years. Lymphoid hyperplasia is observed more oftenamong infants and adults and is responsible for the increased incidence of appendicitisin these age groups. Younger children have a higher rate of perforation, with reportedrates of 50-85%. The median age at appendectomy is 22 years. Although rare, neonatal


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and even prenatal appendicitis have been reported. Clinicians must maintain a highindex of suspicion in all age groups.

Etiology:

Appendicitis is caused by obstruction of the appendiceal lumen. The most commoncauses of luminal obstruction include lymphoid hyperplasia secondary to inflammatorybowel disease (IBD) or infections (more common during childhood and in young adults),fecal stasis and fecaliths (more common in elderly patients), parasites (especially inEastern countries), or, more rarely, foreign bodies and neoplasms.

Fecaliths form when calcium salts and fecal debris become layered around a nidus ofinspissated fecal material located within the appendix. Lymphoid hyperplasia isassociated with various inflammatory and infectious disorders including Crohn disease,gastroenteritis, amebiasis, respiratory infections, measles, and mononucleosis.

Obstruction of the appendiceal lumen has less commonly been associated with bacteria

(Yersinia species, adenovirus, cytomegalovirus, actinomycosis, Mycobacteria species,Histoplasma species), parasites (eg, Schistosomes species, pinworms, Strongyloidesstercoralis), foreign material (eg, shotgun pellet, intrauterine device, tongue stud,activated charcoal), tuberculosis, and tumors.

CLINICAL APPROACH:

Diagnostic Workup

Patients with appendicitis may not have the reported classic clinical picture 37-45% of

the time, especially when the appendix is located in an unusual place. In such cases,imaging studies may be important but not always available. However, patients withappendicitis usually have accessory signs that may be helpful for diagnosis. Forexample, the obturator sign is present when the internal rotation of the thigh elicits pain(ie, pelvic appendicitis), and the psoas sign is present when the extension of the rightthigh elicits pain (ie, retroperitoneal or retrocecal appendicitis).

Laboratory tests are not specific for appendicitis, but they may be helpful to confirmdiagnosis in patients with an atypical presentation.

LABS:

mild leukocytosis with left shift (may have normal WBC counts)

higher leukocyte count with perforation

urinalysis

IMAGING:


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CT scan: This is considered the gold standard for diagnosing appendicitis. Theobservations here could be thick wall, appendicolith, inflammatory changes. The overallaccuracy rate is 94-100%.

Ultrasound: It may visualize appendix. But is not really the choice of the modality.Overall accuracy is about 90-94%. It can rule in but cannot rule out appendicitis (if >6

mm.)

Chest X-ray: Upright CXR, AXR: This is usually nonspecific. One can observe free air ifperforated (rarely). Calcified facecloth if present can be seen. The other possible x-rayobservations could be loss of psoas shadow and RLQ ileum.

Pathophysiology/ Pathogenesis:

The probable sequence of events in acute appendicitis is:

1. Luminal obstruction.

In young patients, more commonly by lymphoid tissue hyperplasia.

In older patients, fecalith is an increasingly common cause of obstruction.


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2. Distention and increased intraluminal pressure.

The appendiceal mucosa continues to secrete normally despite being obstructed.

The resident bacteria multiply rapidly, further increasing intraluminal pressure.

3. Venous congestion.

The intraluminal pressure eventually exceeds capillary and venulepressures.

Arteriolar blood continues to flow in, causing vascular congestion andengorgement.

4. Impaired blood supply renders the mucosa ischemic and susceptible tobacterial invasion.

5. Inflammation and ischemia progress to involve the serosal surface ofthe appendix.

Clinical Course:

The development of appendicitis generally begins with luminal obstruction by a fecalith,lymphoid hyperplasia, or food matter. With this obstruction there is an increase inmucous secretion, venous and lymphatic congestion, and bacterial overgrowth. Whenunabated, this process leads to ischemic necrosis and perforation. The classic history ofacute appendicitis begins with vague pain in the periumbilical region, nausea, vomiting,and the urge to defecate; these symptoms are followed by localization of the pain in theright lower quadrant associated with localized peritonitis. Approximately 20% of patientswith acute appendicitis experience perforation within 24 hours of the onset ofsymptoms. Recognition of appendicitis can be delayed because of atypical

presentations caused by retrocolic or pelvic locations. Similarly, antibiotic administrationduring the early course of appendicitis may alter the clinical course. Only approximately50% of patients with acute appendicitis show a classic presentation.

Prognosis:

Acute appendicitis is the most common reason for emergency abdominal surgery.Appendectomy carries a complication rate of 4-15%, as well as associated costs andthe discomfort of hospitalization and surgery. Therefore, the goal of the surgeon is tomake an accurate diagnosis as early as possible. Delayed diagnosis and treatmentaccount for much of the mortality and morbidity associated with appendicitis.

The overall mortality rate of 0.2-0.8% is attributable to complications of the diseaserather than to surgical intervention. The mortality rate in children ranges from 0.1% to1%; in patients older than 70 years, the rate rises above 20%, primarily because ofdiagnostic and therapeutic delay.

Appendiceal perforation is associated with increased morbidity and mortality comparedwith nonperforating appendicitis. The mortality risk of acute but not gangrenousappendicitis is less than 0.1%, but the risk rises to 0.6% in gangrenous appendicitis.


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The rate of perforation varies from 16% to 40%, with a higher frequency occurring inyounger age groups (40-57%) and in patients older than 50 years (55-70%), in whommisdiagnosis and delayed diagnosis are common. Complications occur in 1-5% ofpatients with appendicitis, and postoperative wound infections account for almost onethird of the associated morbidity.

Plan of Management:

Hydrate, correct electrolyte abnormalities

Surgery (gold standard, 20% mortality with perforation especially in elderly) alongwith the antibiotic coverage

If localized abscess (palpable mass or large phlegmon on imaging and often pain>4-5 d), consider radiologic drainage with antibiotics for 14 days intervalappendectomy in 6 wks

appendectomy: laparoscopic vs. open complications: spillage of bowel contents, pelvic abscess, enterocutaneous fistula perioperative antibiotics:

- ampicillin +gentamicin+ metronidazole (antibiotics x 24 h only if non-perforated)- other choices: 2nd/3rd generation cephalosporin for aerobic gut organisms

colonoscopy in the elderly

Medications:

The following antibiotics are recommended for prophylaxis in uncomplicated

appendicitis : Cefoxitin: 2 grams IV single dose (Adults)

Alternative agents:Ampicillin-sulbactam: 1.5-3 grams IV single dose (Adults) Amoxicillin-clavulanate 1.2 2.4 grams IV single doseFor patients with allergy to beta-lactam antibiotics:

Gentamicin 80-120 mg IV single dose plus Clindamycin 600 mg IV single dose

The recommended antibiotics for therapy of complicated appendicitis in adults are

1) Ertapenem 1 gram IV every 24 hours 2) Tazobactam-piperacillin 3.375 grams IV every 6 hours or 4.5 grams IVevery 8 hours

For adults with beta-lactam allergy: Ciprofloxacin 400 mg IV every 12 hours plus Metronidazole 500 mg IV every 6 hours


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References:

Schwartzs Principles of Surgery, 9th Edition

Toronto Notes 2012

Acute Appendicitis from http://emedicine.medscape.com/article/773895-overview


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