Detailed Treatment Process
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Female, 32 years old Emergency department record on the evening of July 23 at 23:30 (some handwriting illegible due to poor legibility), Abdominal pain and vomiting for 6 hours Mid-upper abdominal pain after dinner, accompanied by nausea and vomiting, no diarrhea, no fever, with a history of gastritis Physical examination: soft abdomen, no tenderness The following is the discharge summary Department: Gastrointestinal Surgery Ward Admission date: July 24 Discharge date: July 30 Admission diagnosis: 1. Acute appendicitis 2. Anemia Discharge diagnosis: 1. Acute appendicitis 2. Anemia Main symptoms and signs on admission: Admitted for “lower abdominal pain for 1 day” No obvious abdominal muscle rigidity. Tenderness noted around the umbilicus and in the mid-lower abdomen. Positive McBurney’s point tenderness and rebound tenderness. No obvious succussion splash or fluid wave. Liver and spleen not palpable below the costal margin. No obvious abdominal masses. Negative shifting dullness. Bowel sounds not hyperactive. No edema in the lower limbs. Main laboratory and special examinations [Emergency biochemistry] (07-24) blood: albumin (dry) 39, direct bilirubin (dry) 0.0, alkaline phosphatase (dry) 66.0, AST (dry) 18.0 U/L, glucose (dry) 5.0, urea (dry) 1.9, potassium (dry) ↓ 3.4, calcium (dry) ↓ 2.06; [Coagulation] (07-24) blood: PT 11.0, INR 0.86, APTT 27.9, fibrinogen 2.60 g/L, TT 24.8; [Blood routine] (07-24) blood: white blood cells 6.50 × 10⁹/L, red blood cells 4.24 × 10¹²/L, platelets ↑ 329 × 10⁹/L, neutrophils ↑ 80.8%, lymphocytes ↓ 14.8%, red cell distribution width ↑ 17.5%, mean platelet volume ↓ 8.7 fL, plateletcrit ↑ 0.29; [Urine routine] (07-24) urine: pH ↑ 7.0; [Body fluid miscellaneous] (07-24) urine: human chorionic gonadotropin negative (-); [Blood routine] (07-25) blood: white blood cells ↑ 9.26 × 10⁹/L, hemoglobin ↓ 91 g/L, hematocrit ↓ 28.8, MCV ↓ 70.1, MCH ↓ 22.1, MCHC ↓ 316, neutrophils ↑ 86.5%, lymphocytes ↓ 8.6%, neutrophil count ↑ 8.0 × 10⁹/L, eosinophil count ↓ 0.0 × 10⁹/L, red cell distribution width ↑ 16.3%; [Immunology] (07-25) blood (immunology 2): HBsAg 0.00, HBsAb 72.05, HBeAg 0.419, HBeAb 1.94, HBcAb 0.08, HCV antibody (ECL) 0.030; [Blood routine] (07-26) blood: C-reactive protein ↑ 64.1, white blood cells 8.48 × 10⁹/L, red blood cells 3.73 × 10¹²/L, hemoglobin ↓ 82 g/L, hematocrit ↓ 26.1, MCV ↓ 70.0, MCH ↓ 22.0, MCHC ↓ 314, neutrophils ↑ 83.9%, lymphocytes ↓ 9.9%, neutrophil count ↑ 7.1 × 10⁹/L, red cell distribution width ↑ 16.8%; (07-27) blood: hemoglobin ↓ 90 g/L, hematocrit ↓ 28.0, MCV ↓ 69.8, MCH ↓ 22.4, MCHC ↓ 321, neutrophils ↑ 81.4%, lymphocytes ↓ 11.6%, lymphocyte count ↓ 0.8 × 10⁹/L, red cell distribution width ↑ 16.6%, mean platelet volume ↓ 9.1 fL; Abdominal erect and supine plain films (7-27): Free intraperitoneal gas. Please correlate with clinical history. Small bowel obstruction. Please follow up clinically. Abdominal erect and supine plain films (7-29): 1. Small amount of free intraperitoneal gas, significantly decreased compared with the abdominal plain film on 7-24. Please correlate with clinical findings. 2. Gas and fluid in parts of the small bowel with multiple short air-fluid levels; intestinal obstruction significantly improved compared with the film on 7-24. Please follow up clinically. Treatment course (including drug names, dosage, route, duration, and process): After admission, preoperative examinations were completed. Urine HCG was performed to rule out pregnancy. After gynecological consultation ruled out gynecological conditions, emergency laparoscopic appendectomy was performed. Postoperative anti-inflammatory treatment was given. The patient developed abdominal distension and discomfort with vomiting after eating. Abdominal erect and supine plain films suggested possible partial small bowel obstruction, considered to be due to postoperative adhesions. The patient was kept nil by mouth with intravenous fluid and nutritional support. After increased activity, the abdominal distension improved markedly. Follow-up abdominal plain films showed significant resolution of the bowel obstruction, and the patient was discharged. Surgery date: July 24 Anesthesia: general anesthesia Procedure: laparoscopic appendectomy Intraoperative findings and key steps: Skin incision approximately 1.0 cm above the umbilicus. First trocar inserted through this incision, connected to the insufflator to create pneumoperitoneum with intra-abdominal pressure maintained at 12 mmHg. The operating table was tilted into Trendelenburg with left tilt. Laparoscope inserted through the umbilical trocar. Additional 0.5 cm trocars placed at the left and right McBurney points. Exploration revealed partial omental adhesions to the right lower abdominal wall and approximately 30 ml of yellow purulent fluid in the peritoneal cavity. Fluid was aspirated. The appendix was identified along the taenia coli. It measured about 5.0 cm in length and 1.0 cm in diameter, with obvious serosal congestion and edema. The mesoappendix was divided and ligated with separating forceps. The appendix base was doubly ligated with Endoloop 0.5 cm from the base and divided. The appendiceal stump mucosa was cauterized with electrocautery. The appendix was removed in a specimen bag. The peritoneal cavity was wiped clean of residual fluid. No active bleeding was found. Counts of gauze and instruments were correct. Surgery completed. Postoperative: no sutures to remove Wound healing: II/A Pathology report: simple appendicitis Symptoms and signs at discharge: The patient reported no significant discomfort. General condition was satisfactory. Vital signs were stable. Alert and oriented, breathing unlabored. No enlarged superficial lymph nodes. Lung sounds clear bilaterally. Heart rate 75 beats per minute, regular rhythm, no murmurs. Abdomen soft and flat, no tenderness or palpable masses. Trocar sites healing well with no discharge, redness, or swelling. Discharge instructions (including drug names, dosage, route, duration, total amount): Gastrointestinal surgery follow-up in 1 week Discharge medications: none Treatment outcome: cured Health education: (omitted) The above is the discharge summary. Subsequently, the pathology report issued by the medical records department concluded subacute appendicitis rather than simple appendicitis. After discharge, the patient continued to experience abdominal discomfort. On August 5, repeat abdominal CT showed swelling of the ileocecal bowel wall with surrounding exudation. After further surgery, the pathology diagnosis was colon cancer. The hospital later provided the patient with financial compensation.