how to write a medical report of a patient who underwent appendicitis surgery

by Martine Mayert DVM 7 min read

Surgery Case Report - Appendicitis | PDF | Medicine

20 hours ago COMPREHENSIVE MEDICAL REPORT ON APPENDICITIS Lorenz Heister (1638-1758), a leading German surgeon, did a post-mortem section of Appendicitis. Claudius Aymand (1681-1740) performed surgery on an 11yr old boy with a right scrotal hernia and a fistula. Identified the … >> Go To The Portal


Can a case report help in the diagnosis of recurrent appendicitis?

The case report could help to improve the awareness of medical practitioners who come across similar cases so that they can consider recurrent appendicitis in their differential diagnosis; and hence outline appropriate diagnosis as well as early medical interventions. Discussion

Does presentation affect the diagnosis of chronic appendicitis?

Chronic appendicitis has often been referred to as a controversial diagnosis and its prevalence is unknown. We present two cases of chronic appendicitis where the patient presentation led the investigations in very different directions, thus delaying the diagnosis.

What is the name of the procedure for appendicitis?

NAME OF PROCEDURE: Laparoscopic appendectomy. PREOPERATIVE DIAGNOSIS: Acute appendicitis. POSTOPERATIVE DIAGNOSIS: Acute appendicitis. ANESTHESIA: General endotracheal anesthesia. COMPLICATIONS: None. FINDINGS: The appendix is acutely inflamed with no evidence of necrosis or perforation. There is no abscess or purulence.

What is the duration of history of recurrent appendicitis?

The current case report presents 18 years of undiagnosed recurrent appendicitis. This had the longest duration of history of recurrent appendicitis among the documented such medical case reports.

How do you describe an appendectomy?

An appendectomy is surgery to remove the appendix when it is infected. This condition is called appendicitis. Appendectomy is a common emergency surgery. The appendix is a thin pouch that is attached to the large intestine.

What assessment findings are noted with appendicitis?

The most specific physical findings in appendicitis are rebound tenderness, pain on percussion, rigidity, and guarding. Although RLQ tenderness is present in 96% of patients, this is a nonspecific finding.

What should I look for after appendix surgery?

Your belly may be swollen and may be painful. If you had laparoscopic surgery, you may have pain in your shoulder for about 24 hours. You may also feel sick to your stomach and have diarrhea, constipation, gas, or a headache. This usually goes away in a few days.

What is the expected outcome of an appendectomy?

Appendicitis is one of the most common surgical emergencies requiring appendectomy, with a life-time risk of 6%. The overall mortality rate for open appendectomy (OA) is around 0.3% and morbidity about 11%.

What is the nursing diagnosis for appendicitis?

Diagnosis. Based on the assessment data, the most appropriate diagnoses for a patient with appendicitis are: Acute pain related to obstructed appendix. Risk for deficient fluid volume related to preoperative vomiting, postoperative restrictions.

What are some nursing diagnosis for appendicitis?

Nursing DiagnosisAcute pain related to obstructed appendix.Risk for fluid volume deficit related to nausea and/or vomiting/ decreased appetite/ decreased fluid intake.Risk for infection related to ruptured appendix/ surgical incision.Risk for deep venous thrombosis (DVT) related to immobility.More items...•

Which food is good after appendix surgery?

What to eatWell-cooked soft cereals.Mashed potatoes.Plain toast or bread.Plain crackers.Plain pasta.Rice.Cottage cheese.Pudding.More items...

What are the complications of appendicitis?

If your appendix bursts, the lining of your abdomen (peritoneum) will become infected with bacteria. This is called peritonitis....Peritonitissevere continuous abdominal pain.feeling sick or being sick.a high temperature.a rapid heartbeat.shortness of breath with rapid breathing.swelling of the abdomen.

Do and don'ts after appendix surgery?

Taking care of yourself at home after appendectomy Drink plenty of water every day to help prevent constipation. Make sure you have adequate rest. A fast lifestyle, with inadequate diet, will slow your recovery. Avoid lifting heavy objects and stair climbing, so that you don't strain your abdominal muscles.

What is the ICD 10 code for appendectomy?

ICD-10-CM K35. 33 is grouped within Diagnostic Related Group(s) (MS-DRG v39.0): 338 Appendectomy with complicated principal diagnosis with mcc. 339 Appendectomy with complicated principal diagnosis with cc.

What is the most common surgical emergency in the world?

Appendicitis is the most common life threatening abdominal surgical emergency globally [1] that requires prompt intervention [2]. Physicians from a wide range of medical specialties including internal medicine and pediatrics, as well as surgeons encounter patients with this condition in their daily practice [3].

Is recurrent appendicitis a surgical emergency?

Unlike a cute appendicitis, recurrent appendicitis is not considered a surgical emergency [19]. Diagnosis can be missed or delayed secondary to atypical presentation or prior treatment with antibiotics, which may lead to resolution of the infection [20].

Can appendicitis be missed?

Recurrent appendicitis can be missed or delayed secondary to atypical presentation or prior treatment with antibiotics, which may lead to resolution of the infection. Missed diagnosis can lead to serious complications such as perforation, abscess formation and peritonitis.

What are some examples of medical reports?

For some of the more in-depth and extensive examples, the different kinds of medical reports often include radiology reports, printable laboratory reports, and pathology reports.

Why is it important to use professional language in medical reports?

Use professional language and ensure that there is enough clarity to prevent any misunderstandings among all of the involved parties.

Can you keep a copy of a medical report?

The creation of a medical report may dictate that you keep a separate but identical copy for yourself. The purpose of doing so is purely related to documentation. Also, in the event that the original medical report is somehow lost or tampered with, the patient can always turn back to you for references.

Is a medical report vague?

A medical report that comes off as vague is practically useless. For it to be valid and useful, the medical professional writing it must go into detail. With that said, use specific terms and provide particular comments and suggestions for the benefit of the report’s recipient.

Abstract

Chronic appendicitis is a condition unfamiliar to many physicians and is often referred to as a controversial diagnosis. This can give rise to diagnostic delay.

Background

In general practice, patients frequently present with abdominal pain, with a high prevalence of acute underlying disease [ 1 ]. Acute appendicitis is among the common differential diagnoses, with an estimated lifetime risk of 7–8% [ 2 ]. Chronic appendicitis has often been referred to as a controversial diagnosis and its prevalence is unknown.

Case presentation

A 21-year-old Caucasian woman, previously healthy and asymptomatic with no family history of abdominal disease, presented with 2 months of recurrent, dull abdominal pain in the upper part of her abdomen with no radiation that lasted for 1–2 days approximately twice a week.

Discussion

Chronic appendicitis is a diagnosis unfamiliar to many clinicians, and with no official diagnostic criteria. A symptom duration of > 7 days of chronic or recurrent abdominal pain has previously been suggested to distinguish between acute and chronic appendicitis [ 3 ].

Conclusion

With these two case stories, we wish to draw attention to chronic appendicitis as a possible differential diagnosis in younger patients with chronic or recurrent abdominal pain, particularly if the pain is located to the lower abdomen and is accompanied by fever. Radiological imaging with ultrasound and/or CT scan can be useful.

Availability of data and materials

All data analyzed during this study are included in this published article.

Abbreviations

18 F-fluoro-2-deoxy- d -glucose positron emission tomography/computed tomography

Nursing Care Plans

Nursing care planning and management for patients who underwent appendectomy includes: preventing complications, promoting comfort, and providing information.

See Also

Nursing Care Plan: The Ultimate Guide and Database – the ultimate database of nursing care plans for different diseases and conditions! Get the complete list!