BRIDGING PBL

MIDTERM EXAM

NAME: YOUSEF LABABNEH

E-MAIL:
YLABABNEH@NEWVISION.GE

GROUP 18

DOCTOR: MARI RODONAIA

CASE: ALEX PAM

SENDING DATE: 17/05/2022

 Table of Contents
TABLE OF CONTENTS ......................................................................................................................................1
PATIENT PRESENTATION ................................................................................................................................3
Q1: KEY INFORMATION: .......................................................................................................................................... 3
Q2: HYPOTHESES CAUSES OF ACUTE ABDOMINAL PAIN: ................................................................................................. 4
Q3: WHICH HYPOTHESES DO YOUR GROUP CONSIDER MOST LIKELY TO EXPLAIN ALEX’S PROBLEM(S) AT THIS STAGE?.................. 5
Q4: WHAT QUESTIONS WOULD YOU ASK ALEX AND HIS MOTHER IN ORDER TO HELP YOU CHOOSE BETWEEN YOUR HYPOTHESES? . 6
Q5: WHAT ASPECTS OF A PAIN MIGHT HELP TO ASK? ..................................................................................................... 7
HISTORY .........................................................................................................................................................8
Q6: WHAT NEW INFORMATION DO YOU HAVE ABOUT ALEX’S PROBLEMS? ......................................................................... 8
Q7: DOES ANY OF THIS INFORMATION MAKE ANY OF YOUR GROUP’S HYPOTHESES MORE OR LESS LIKELY? ................................ 8
Q8: ARE THERE ANY NEW HYPOTHESES? IF SO, PROVIDE A RATIONALE. ............................................................................. 8
Q9: WHAT IS PARACETAMOL? HOW ARE DRUGS GIVEN? (ROUTE OF ADMINISTRATION), HOW DOES THE DRUG DISTRIBUTE ITSELF
IN THE BODY? HOW DOES THE BODY ELIMINATE THE DRUG? CAN PARACETAMOL BE GIVEN ANY OTHER WAY? ......................... 9
Q10: WHAT INFORMATION WOULD YOU SEEK FROM A PHYSICAL EXAMINATION THAT WOULD CONFIRM OR REFUTE EACH OF YOUR
CHOSEN HYPOTHESES? ........................................................................................................................................... 10
Q11: WHAT IS THE RELATIONSHIP BETWEEN THE LOCATION OF THE PAIN AND THE STRUCTURES INSIDE THE ABDOMEN? ........... 10
PHYSICAL EXAMINATION.............................................................................................................................. 10
Q12: DOES INFORMATION FROM THE PHYSICAL EXAMINATION SUPPORT OR HELP ELIMINATE ANY OF YOUR HYPOTHESES? WHAT
ARE YOUR TOP 3 HYPOTHESES NOW? ........................................................................................................................ 11
Q13: ARE THERE ANY NEW PROBLEMS, OTHER THAN THE ABDOMINAL PAIN? IF SO, WHAT ARE THEY? ................................... 11
Q14: WHAT IS THE SIGNIFICANCE OF THE DRY MOUTH, SUNKEN EYES AND THE CONCENTRATED URINE? ................................ 11
Q15: HOW HAVE THEY OCCURRED? ......................................................................................................................... 11
PATIENT MANAGEMENT .............................................................................................................................. 12
Q16: EXPLAIN THE MECHANISM BY WHICH THE INTRAVENOUS SODIUM CHLORIDE 0.9% SOLUTION WATER WILL DISTRIBUTE ITSELF
IN ALEX’S BODY. ................................................................................................................................................... 12
Q17: WHY SODIUM CHLORIDE 0.9% SOLUTION? ...................................................................................................... 12
Q18: WHY ARE DIFFERENT DRUGS GIVEN FOR PAIN RELIEF? COMPARE AND CONTRAST THE PROPERTIES OF PARACETAMOL AND
MORPHINE .......................................................................................................................................................... 12

FURTHER EVENTS ......................................................................................................................................... 13

Q19: DO THE OPERATION FINDINGS SUPPORT YOUR TOP HYPOTHESIS? ........................................................................... 15
Q20: WHAT IS YOUR TOP HYPOTHESIS NOW? ............................................................................................................ 15
Q21: WHAT DO YOU NEED TO KNOW TO UNDERSTAND THESE FINDINGS? ........................................................................ 15
Q22: CLARIFY ANY TERMS OR PROCEDURES YOU ARE NOT FAMILIAR WITH. ...................................................................... 15
FURTHER OPERATION FINDINGS .................................................................................................................. 15
Q23: CAN YOU EXPLAIN THE OPERATION FINDINGS AND DR SEMENS’S ACTIONS?.............................................................. 16
FURTHER PHYSICAL EXAMINATION .............................................................................................................. 16
Q24: WHAT IS HAPPENING? .................................................................................................................................. 16
Q25: WHERE DOES AIR GO AFTER IT ENTERS THE MOUTH? ........................................................................................... 17
Q26: WHAT IS THE SITE OF PULMONARY GAS EXCHANGE? ............................................................................................ 17
Q27: HOW DOES OXYGEN GET INTO THE BLOOD AND HOW IS IT TRANSPORTED? ............................................................... 18
Q28: WHICH PART OF THE CIRCULATION DOES IT ENTER? ............................................................................................. 18
Q29: HOW DOES IT THEN GET TRANSFERRED TO THE CAPILLARY BEDS OF THE GENERAL CIRCULATION? .................................. 18
Q30: WHAT IS OXIMETRY ..................................................................................................................................... 18
FURTHER HISTORY ....................................................................................................................................... 18
FURTHER EVENTS ......................................................................................................................................... 19

1
 Q31: WHAT IS THE PURPOSE OF THE ALCOHOL RUB? ................................................................................................... 19
Q32: DISCUSS THE INTERACTION BETWEEN DR SEMENS AND MRS PAM. ........................................................................ 20
HISTOPATHOLOGICAL REPORT: .................................................................................................................... 20
Q33: CLARIFY ANY TERMS ON THE REPORT - SEROSAL CONGESTION, SUPERFICIAL EXUDATE, MESOAPPENDICEAL FAT, VISIBLE
LYMPHOID HYPERPLASIA, YERSINIAL INFECTION, MESENTERY LYMPHADENITIS.................................................................... 20

CLINICAL GOVERNANCE ............................................................................................................................... 21

Q34: WHAT IS CLINICAL GOVERNANCE? ................................................................................................................... 21
Q35: DESCRIBE THE PURPOSE OF THE AUDIT CYCLE IN RELATION TO THIS HOSPITAL’S NEGATIVE APPENDICECTOMY RATE. .......... 21
FURTHER EVENTS ......................................................................................................................................... 22
Q36: WHAT IS APPRAISAL? ................................................................................................................................. 22
CONCLUSION: .............................................................................................................................................. 23
FINAL DIAGNOSIS: ........................................................................................................................................ 24
REFERENCES: ................................................................................................................................................ 25
BOOKS: ............................................................................................................................................................ 25
WEBSITES : ....................................................................................................................................................... 25

2
 PATIENT PRESENTATION
On Monday evening at 9 o’clock Alex Pam, 8 years old boy arrives at the
emergency department accompanied by his mother and 2 years old brother.
The boy does not look healthy: flushed face, sunken eyes, and stomach-ache
complaints.
His little brother cries and twirls in the stroller.
They start to talk with Dr. Timoff:
‘Hello Alex! I am your doctor, my name is Mike, tell me about your tummy.
Where does it hurt?”

Q1: Key Information:

v Alex is an 8 years old male named Alex Pam.
v Alex is admitted to the ER accompanied by his mother and his 2 years
old brother.
v Alex is not looking well, he is flushed face, sunken eyes, and complains
1of stomach-ache.
v His little 2 years old brother is crying and twirling in his stroller causing a
fuss at the ER.
v Dr. It off introduce his self and questions Alex about his pain (physical
diagnosis) using a proper language for the patient to understand and
express his pain clearly and fully.

3
Q2: Hypotheses
Causes of acute abdominal pain:

No. Hypotheses Symptoms Why this?

1 Appendicitis 1. Abdominal pain Alex complained that he has a
2. Fever stomach ache and sunken eyes
3. Loss of appetite these are symptoms of
4. Diarrhea appendicitis.
5. Nausea
6. Vomiting
7. Swollen
2 Dehydration 1. Vomiting & diarrhea Alex sunken eyes indicates that
(especially in infants & he might be dehydrated or
children) malnutrition, or diarrhea.
2. Drugs that increase
urine excretion
(diuretics)
3.Decreased water
intake
4. Burns
5. Heat
6.. Excessive sweating
particularly with
prolonged exertion
3 Allergies 1.Sunken eyes Alex is having sunken eyes and a
(asthma\ 2. flushed face flushed face which is a sign of
eczema) 3. sneezing allergies.
4.runny nose red
5.watering eyes
6.vomiting
4 Sinus infection 1. Thick, yellow or Alex has a symptom of sunken
greenish mucus from the eyes which is a sign of sinus
nose (runny nose) or infection.
down the back of the
throat (postnasal
drainage)
2. Blocked or stuffy nose
(congestion) causing
difficulty breathing
through your nose
3. Pain, tenderness,
swelling and pressure
around your eyes,

4
 cheeks, nose or
forehead that worsens
5 Vitamin 1. easy bruising Kids at a younger age might have
deficiencies 2.slow wound healing vitamin deficiency.
3.dry scaly skin
4.frequent nosebleeds
6 Sleep issues Sunken eyes Alex is admitted while his Little
brother is around which might
indicates he might have some
sleep deprivation.
7 Food poisoning 1. Nausea Kids at a younger age tend to
2. Vomiting miss around at some unhygienic
3. Diarrhea conditions,
4. Abdominal cramps
5. Loss of appetite
6. Mild fever
7. Weakness
8. Headaches
8 trauma 1. Stomach ache Kids at his might suffer from
2. flushed face trauma without being
knowledge of its condition
(school, playground,…etc.)
9 UTI - Urinary 1. Pain Viral infection might be the
tract infections 2. Tiredness cause for all the mentioned
3. Chills symptoms due to some
4. Blood in urine unhygienic environment.
5. Loss of control of
urine
10 Gastroenteritis 1. Lost of appetite Cause might be due to a viruse
2. Bloating such as (astrovirus,adenovirus).
3. Abdominal pain /
crumps
4. Diarrhea
5. Nausea
6. Vomiting

Q3: Which hypotheses do your group consider most likely to explain Alex’s
problem(s) at this stage?
1. Allergies because it is a very common seasonal symptoms
2. Sleep issues, Alex is admitted while his Little brother is around which might
indicates he might have some sleep deprivation.

5
Discussion questions :
Q4: What questions would you ask Alex and his mother in order to help you
choose between your hypotheses?
To Alex
1. Does the pain radiates at his stomach?
2. Do you have any allergies?
3. How does this condition impacted his activities?
4. How often does this occur ?
5. How long has this been occurring?
6. What is the pain like
7. When does it occur, and what relieves it?
8. Have you suffered from any physical injures in past few days?
To the Mom
1. Does Alex have any allergies?
2. What is his food intake in the past days, has Alex tried any new food ?
3. Is his little brother showing any similar signs of sickens (infection)?
4. Do you have a personal or family history of asthma, eczema, or any
other type of allergies ?
5. Has Alex been in any type trauma in the past few days?

6
 Q5: What aspects of a pain might help to ask?
Use the SOCRATES model for ask questions of the pain:

❖ Where is the pain?

Site
❖ Can you point to where you experience the pain?
❖ Did the pain come on suddenly or gradually?
❖ When did the pain first start?
Onset ❖ Did the pain come on at rest or whilst you were exerting
yourself?
❖ How long did the pain last for?
❖ How would you describe the pain?
Character
❖ Is the pain constant or does it come and go?
❖ Does the pain spread elsewhere?
Radiates ❖ Does it radiate into the neck, shoulder, back, or down your
arm?

❖ Please tell me about any symptoms you might be having in

your chest
❖ Are there any associated symptoms other than shortness of
Associated
breath such as sweating, palpitations, or nausea?
Symptoms
❖ Have you noticed anything else that accompanies it?
❖ Are there any other symptoms that seem associated with
the pain?
❖ How has the pain changed over time?
❖ When did (does) it start?
Time ❖ How long does it last?
❖ How often does it come?
❖ Does it ever wake you up at night?
❖ Is there anything that makes it better or worse?
Exacerbating ❖ Is the pain related to exertion?
❖ What kinds of activities bring on the pain?
Severity ❖ How intense is the pain, on a scale of 1 to 10?

7
 HISTORY
Pain complaints started in the morning before school. Later, when Alex
vomited twice, mother received a call from the school. Nanny picked up the
boy back home. Mother came at 7pm home after her work. Alex did not eat
or drink anything during the day. The pain is located right at the bottom of
the stomach: progressing during the day, primary felt intermittently, then
continuously. Paracetamol did not reduce the pain. There is no pain in the
testicles: no burning sensation when he urinates, no diarrhea and
constipation. The boy caught a cold and had a sore throat for the past 48
hours.
In general, the child is healthy, no experience of the abdominal pain. Alex
does not suffer from allergies, and has not take in any medication on a
regular basis. He lives with his mother, who works as a lawyer. Father is a
corporate lawyer, who works in another city during the week.
History Discussion Questions :
Q6: What new information do you have about Alex’s problems?

❖ The pain is located right at the bottom of the stomach: progressing

during the day, primary felt intermittently, then continuously.
❖ Paracetamol did not reduce the pain.
❖ There is no pain in the testicles
❖ No burning sensation when he urinates,
❖ No diarrhea and constipation.
❖ Alex caught a cold and had a
❖ Sore throat for the past 48 hours.

Q7: Does any of this information make any of your group’s hypotheses more
or less likely?
Yes, Alex has no any type of allergies, same as no diarrhea or constipation
which rules out ore hypotheses of dehydration and allergies.

Q8: Are there any new hypotheses? If so, provide a rationale.

At this point no new hypotheses were made, but based on the initial
hypotheses we can match them for the most of these two: Appendicitis or
Gastroenteritis.

8
Q9: What is paracetamol? How are drugs given? (route of administration),
How does the drug distribute itself in the body? How does the body
eliminate the drug? Can paracetamol be given any other way?
® Paracetamol is a common painkiller used to treat aches and pain. It can
also be used to reduce a high temperature.
® It's available combined with other painkillers and anti-sickness medicines.
It's also an ingredient in a wide range of cold and flu remedies.
® Paracetamol tablets, syrup and suppositories come in a range of strengths.
Children need to take a lower dose than adults, depending on their age.
Paracetamol tablets (including soluble tablets), syrup and suppositories
are available on prescription
® After a drug gains access to the bloodstream, the blood “distributes” it to
the body’s tissues.
® How that happens depends a lot on the drug’s properties.
® For example, fat-soluble drugs (like prednisone, a steroid used to treat
inflammation) seek out fat cells where they easily dissolve and pass
through cell membranes. Water-soluble drugs, such as atenolol, used to
treat high blood pressure, stick around in the blood and the fluids
surrounding cells.
® Another factor affecting distribution is whether the drug is made up of
large or small molecules. Most drugs used therapeutically are small
molecule drugs—and for good reason. Small molecule drugs, such
as Nexium (used to treat gastroesophageal reflux disease), pass easily
through cell membranes so they can continue their journey. Large
molecule drugs, such as insulin, have a harder time permeating
membranes and are best given by injection.
® The elimination of drugs from the body involves the processes of
metabolism and excretion. the Liver and drug metabolism RLO, Excretion
is the removal of waste substances from body fluids, and predominantly
occurs via urine formed in the kidneys. Other routes of excretion from the
body can include in bile, saliva, sweat, tears, feces, milk and exhaled air.
® Most drugs are metabolized first prior to being excreted. However, some
drugs, such as aminoglycoside antibiotics are polar compounds and are
excreted by the kidneys without being metabolized first.

9
Q10: What information would you seek from a physical examination that
would confirm or refute each of your chosen hypotheses?
Inspection of the abdomen (trauma, scares, skin color discoloration)
Auscultation of bowel movement sounds, intestine obstruction, fraction rubs,
Palpation , Assessing Possible Acute Cholecystitis, “McBurney point”, blood
test, and imaging test such as CT scan, MRI.

Q11: What is the relationship between the location of the pain and the
structures inside the abdomen?
A pain the lower right side of the stomach might indicate an issue in the
A. small intestine
B. Appendix
C. Cecum and the ascending colon
Somatic pain is well localized, It is located asymmetrically and intensified by
jarring, deep inspiration or pressure on the abdominal wall.

PHYSICAL EXAMINATION
Physical examination is performed on the couch and yields with this
information:
flushed face: dry mouth: sunken eyes: temperature 38: pulse 120: blood
pressure of 80 \ 60: respiratory rate 20:
height 125cm: weight 23.5kg: no chest pathology: The abdomen moves
during respiration.
Doctor warms up his hands and gently palpates Alex’s stomach. During
palpation, he asks questions about the school and follows up the boy’s face.
There are: a moderate pain in the right iliac fossa: painful stomach during
coughing: active bowel sounds: normal hernial opening .
Rectal examination is not performed. Alex provides a concentrated urine.

10
Physical diagnoses Discussion questions:
Q12: Does information from the physical examination support or help
eliminate any of your hypotheses? What are your top 3 hypotheses now?
Yes, due to the fact that these new symptoms and physical examinations
matches our hypotheses:
A. Appendicitis
B. lymphadenitis (mesenteric)
C. kidney infection
Appendicitis: The painful stomach during coughing or moving is one of the
symptoms that support the appendicitis hypotheses also while taking deep
breath.
lymphadenitis (mesenteric) : - stomach pain - Fever 38 or higher - dry mouth
Kidney infection: nausea, vomiting fever, chills.

Q13: Are there any new problems, other than the abdominal pain? If so,
what are they?
v Dry mouth
v temperature 38 (fever)
v blood pressure 80\60 (hypotension)
v RR: 20 (Tachypnea)
v low BMI approximately 15 (normal weight 31.25 – 39)
v moderate pain in the right iliac fossa concentrated urine
v painful stomach during coughing

Q14: What is the significance of the dry mouth, sunken eyes and the
concentrated urine?
Dry mouth, sunken eyes and concentrated urine could be the signs of serious
dehydration.
Q15: How have they occurred?
v This dehydration is due to the fact that Alex is not eating and drinking all
day because of his illness
v due to the fact that his appendicitis in infected.
v Lymphadenitis an inflammation of lymph nodes

11
 PATIENT MANAGEMENT
Dr. Tim explains that he is going to call surgeon on duty, Dr. Semens, in order
to examine the child, because there is a chance of appendicitis.
“Still we are not sure about the diagnosis, but in the case of surgery child
should not eat. Alex has low blood pressure because there is not enough fluid
circulating in the body. We need to put an IV and give pain relief”
A morphine injection is done intramuscularly.
After smoothing skin with a painkiller cream Dr. puts an intravenous drop
counter. She writes: 0.9% sodium chloride solution (1 liter).
The doctor evaluates approximate loss of body fluid boy (due to vomiting,
and perspiration due to the temperature) in order to calculate the amount of
fluid injected.
PATIENT MANAGEMENT QUESTIONS:
Q16: Explain the mechanism by which the intravenous Sodium Chloride 0.9%
solution water will distribute itself in Alex’s body.
Active sodium/potassium pumps keep intracellular concentration of potassium
high and sodium low, with reverse true for plasma, chloride closely follows the
physiological disposition of the sodium cation in maintenance of acid-base
balance, isotonicity and electrodynamic characteristics of cells

Q17: Why Sodium Chloride 0.9% solution?

It was given to him to replace lost body fluids and salts that he had in a result
from not eating and drinking, to compensate his loss of fluid.

Q18: Why are different drugs given for pain relief? Compare and contrast the
properties of paracetamol and morphine
. -The other drugs were given because the paracetamol didn’t help and the
pain still there. (Also morphine used to relieve severe pain caused by major
trauma or surgery).
v Morphine:
® Molar mass- 285.34 g/mol
® Metabolism- hepatic 90%
® Duration of action- 3-7 hours
v Paracetamol:
® Molar mass- 151.163 g/mol
® Metabolism- predominantly in the liver
® Onset of action by mouth-37min / by IV-8min

12
 FURTHER EVENTS
Dr. Semens examines the boy and to be hospitalizes him. Doctor is very busy.
The boy”s mother left hospital, it was not possible to talk with Doc.Semens.
She”s going to come back in the morning
as soon as the nanny will come back in the morning in order to stay with little
child. Alex is very upset and disturbed,
but by midnight he falls asleep.
Later he wakes up and begins to cry, he is looking for mother. Nurce tries to
calm him down and calls Alex”s mother.
Mother asks to connect with Dr.SEMENS, but however Doctor cannot talk
because he is busy with another patient in
other room.
It is 3 am and mother is nervous.
“Hello. Is this Dr. Semens? “
“Yes, how can I help you?”
“What is the result of a urine test?”
“The result is normal, the kidneys and urinary tract infection is improbable”
“The boy was crying and he seems to getting worse”
“Now the best way - is to wait. We will check his condition at 7 am. It”s
difficult for kids to stay at hospital without,
we need to look at the situation objectively “.
Doctor put off the phone without finishing the conversation. After 10
minutes Mr. Deev is calling, Alex”s father.
“Hello, doctor, I am Alex”s father. Am I correct that our son will not be
examined till the morning?”
“It”s almost morning and the nurse usually informs me about significant
changes”
“I know that you are very busy, but I am also aware of cases when patients
remain untreated for a long period of
time. Something must be done “, - says father. “I think that you must
examine my son now, and I”m looking forward for your call”.

13
FURTHER EVENTS DISCUSSION QUESTIONS
v Does Dr Semens have an ethical obligation to accede to Alex’s father’s
request for immediate assessment?

No, due to the fact that the doctor works under a protocol which
organizes and help to determine the priority of cases viewed by him
based on several aspects to assure that every patent is getting the
proper care.

FURTHER HISTORY
Doctor Semens is shrinked in time.
It is difficult to analyze Alex’s condition, as he is anxious, no improvements
are visible.
Dr. Semens discuss the situation with the relevant services and the morning
surgery of appendectomy is
scheduled.
Mrs. Pam comes at 7.30, goes to Alex’s room, which looks a little bit better
after mother’s arrival.
The boy is given an oxygen mask and an intravenous injection that plunges
him into unconsciousness.
Then the intravenous muscle relaxant is given.
As soon as his muscles relaxed Alex is intubated and connected to a
breathing machine.
The main parameters of the vital functions (such as heart rate, respiration,
oxygen saturation and blood pressure) are constantly monitored.
Meanwhile, Dr. Semens washes hands wish chlorhexidine antiseptic, putting
on sterile gown with ‘no touch’
technique.
The patient’s skin is cleaned with a solution of iodine.
He makes an incision through the skin and relaxed muscles of the abdominal
wall over McBurney’s point
and pulls out the appendix from the wound.
Appendix is pale, with a slight pink color.

14
Further History Dicussion Questions:
Q19: Do the operation findings support your top hypothesis?
Absolutely yes, after Dr. Semens examination of the appendix he finds out it is
pale with a slight pink color which favors our hypotheses.

Q20: What is your top hypothesis now?

Appendicitis because all of the symptoms and physical examinations favors our
appendicitis.

Q21: What do you need to know to understand these findings?

v Blood test to check signs of infections.
v Urine test to rule out urinary tract infection.
v Imaging test, such as an abdominal ultrasound or CT scan.

Q22: Clarify any terms or procedures you are not familiar with.
McBurney point corresponds to the location of the base of the appendix and is
found by placing the little finger of one hand in the umbilicus and the thumb
on the anterior superior ileal spine.

FURTHER OPERATION FINDINGS

During examination enlarged mesenteric lymph nodes (mesentery) are
visible and excess fluid.
Dr. Semens makes sure that everything is under control, looking at 20
centimeters distal ileum.
He removes pale appendix and sends it for histopathological examination.
The incision is sutured (closed) and the doctor goes to make the necessary
notes.

15
DISCUSSION QUESTIONS
Q23: Can you explain the operation findings and Dr Semens’s actions?
It was reported that there is an enlargement in the mesenteric lymph nodes,
which that confirms the presence of appendicitis, which caused the swelling.
Dr.Semens continued the surgery after determining the exact location of the
appendix and sent it to follow up the histopathological examination on it for
more details. He completed the operation by closing the incision he had made
then he noted the necessary notes about the operation.

FURTHER PHYSICAL EXAMINATION

Anesthesiologist Dr. Torrent reverses the blockade of the muscles and puts
off gas anesthesia.
Alex is in a semi-conscious condition and is breathing spontaneously.
He is extubated and mechanical ventilation is performed (ventilation with a
bag).
There is the sound of air during inhalation.
But no movement of air out of the bag. Alex’s mouth is open.
Chest movement is visible, as well as the retraction of the trachea.
Indications of blood oxygen saturation (the pulse oxymeter) on the finger of
the child is falling from 99% to
85% over the next few minutes.

Questions:
Q24: What is happening?
While Alex begins to be semi-conscious by putting off the gas anesthesia,
Dr.Torrent noticed abnormality in the oxygen saturation, the oxygen level is
low after falling to 85%. (It’s noticed by the abnormal movement of the bag
that used for mechanical ventilation)

16
Q25: Where does air go after it enters the mouth?
When you breathe through your mouth or nose, the air moves down the
pharynx and into your trachea, which is the windpipe. There are two air
passages in your trachea, and one of these leads to the left lung and the other
to the right lung. These passageways are designed to allow the air to flow
freely into and out of the lungs, and they need to be free of mucus and
inflammation to perform their best.

Q26: What is the site of pulmonary gas exchange?

Gas exchange takes place in the millions of alveoli in the lungs and the
capillaries that envelop them. As shown below, inhaled oxygen moves from the
alveoli to the blood in the capillaries, and carbon dioxide moves from the blood
in the capillaries to the air in the alveoli.

17
Q27: How does oxygen get into the blood and how is it transported?
Inside the air sacs, oxygen moves across paper-thin walls to tiny blood vessels
called capillaries and into your blood. A protein called hemoglobin in the red
blood cells then carries the oxygen around your body.
Q28: Which part of the circulation does it enter?
Blood circulation starts when the heart relaxes between two heartbeats: The
blood flows from both atria (the upper two chambers of the heart) into the
ventricles (the lower two chambers), which then expand.
Q29: How does it then get transferred to the capillary beds of the general
circulation?
By diffusion process: oxygen moves from the alveoli to the blood though the
capillaries lining the alveolar walls once in the bloodstream, oxygen gets picked
up by the hemoglobin in red blood cells.
Q30: WHAT is oximetry
Oximetry is a test used to measure the oxygen level of the blood, painless
measure of how well oxygen is being sent to parts of the body furthest from
the heart, such as arms and legs.

FURTHER HISTORY
Senior anesthesiologist comes and takes a ventilation bag (bag) with 100%
oxygen.
He gently carries out a positive pressure through the bag as long as Alex
coughs and breathes in.
After that, the child starts to breathe spontaneously and saturation returns
to normal level.
Alex is transferred to the post-surgery ward, where his mother is waiting.
His pulse, blood pressure, respiratory rate and oxygen saturation is
monitored regularly.
Intravenous morphine injection is given in order to relief the pain.
Although Alex is still sleepy, he tries to open his eyes and reaches for the
hand of his mother.

18
 FURTHER EVENTS
Later in the afternoon, Dr. Semens comes to examine the boy, where he
meets Alex’s mother also.
His working hours are finished and it is clear that he is more relaxed than
before.
Before examine the child, he rubs his hands with an antiseptic (uses the
alcohol rub).
The doctor explains the boy’s mother, that the results do not confirm
appendicitis operation, but rather
indicate mesadenitis (mesenteric adenitis).
Microscopic analysis of the appendix is expected, that will shows a more
accurate picture.
The doctor continued talking, explaining that the symptoms in both cases are
very similar and mesadenitis
mimics appendicitis, which is explained by an increase in the lymph nodes
around the appendix and swelling in
response to infection, which in the case of Alex could be the result of a cold
and sore throat.
In response, Mrs. Pam replies irritably: “ Thank you Doctor! I understand
that, but it would be better to
discuss it earlier, before Alex was sent to the operating table! “
Doctor apologizes.
Awkward silence comes in the room.
Dr. Semens leaves the room.
The next day Alex returns back home and feels well.

DISCUSSION QUESTIONS
Q31: What is the purpose of the alcohol rub?
Antiseptic soaps should rapidly eliminate transient skin flora and reduce
resident flora on the hands to a minimum during a surgical procedure, and
thus lower the risk of surgical site contamination if surgical gloves are
perforated or torn during surgery.

19
Q32: Discuss the interaction between Dr Semens and Mrs Pam.
Dr.Semens told Ms.Pam about the changes he had seen during the operation
as well as the appendix, which was caused by the similarity of the symptoms
that caused the enlargement and the ill, and he told her about continue
examining the appendix that was removed to reach the most accurate picture
and findings, and that may have caused Ms.Pam a little dissatisfaction and told
him that he had to inform her about these changes before performing the
operation.

Histopathological report:
A week later the doctor receives histological results.
Histopathological report:
Gross appearances: appendix (measuring 40x8mm) with minor serosal
congestion, but without superficial
exudate. A small amount of mesoappendiceal fat is visible.
Microscopic picture: Visible lymphoid hyperplasia of the appendix. No acute
inflammation and, hence, no
signs of acute appendicitis. Question to consider is about Yersinial infection
or other reasons that might cause
mesentery lymphadenitis.
Conclusion - Appendix with lymphoid hyperplasia, no acute inflammatory
process
Consultant - Histopathologist: R.Volf

DISCUSSION QUESTIONS
Q33: Clarify any terms on the report - Serosal congestion, superficial exudate,
mesoappendiceal fat, Visible lymphoid hyperplasia, Yersinial infection,
mesentery lymphadenitis.
v Serosal congestion: congestion of the subserosal blood vessels as
a result of the inflammatory process.
v Superficial exudate: inflammatory reaction on the surface of the
appendix caused by an extra appendiceal source of inflammation.
v Mesoappendices fat: fold of peritoneum around the vermiform
appendix and one of the abdominal cavity.
20
 v Visible lymphoid hyperplasia: thickening of the hypoechoic
laminate propria
v Yersinal infection: infection that associated with acute
appendicitis. (Caused most often by eating raw)
v Mesentery lymphadenitis: also called mesenteric adenitis is an
inflammation of the lymph nodes in the membrane that connects
your bowel to the abdominal wall (mesentery).

CLINICAL GOVERNANCE
Dr Semens adds the case to a 6 month audit of appendicectomies at the
hospital department, (which is a general surgical department rather than
exclusively dealing with pediatric surgery).
Dr Semens notes that his own negative appendicectomy rate (13% all ages,
17% children) is no higher than
his departmental colleagues, at all ages or for children.
However, his pediatric negative appendicectomy rate is higher than figures
from a pediatric surgical
service (12%). In addition, he feels some disquiet about how Alex’s case
went…..

DISCUSSION QUESTIONS
Q34: What is clinical governance?
Clinical governance is the system through which NHS organization are
accountable for continuously improving the quality of their services and
safeguarding high standards of care by creating an environment in which
clinical excellence will flourish.
Q35: Describe the purpose of the audit cycle in relation to this hospital’s
negative appendicectomy rate.
Negative appendectomy is the removal of the normal appendix in the patient’s
presumed to be having acute appendicitis. Audit in health care is a process
used by health professionals to asses, evaluating and improve care of patients
in a systemic way . Audit measures current practice against a defined standard.
It forms part of clinical governance, which aims to safeguard a high quality of
clinical care for patients. They should: identify the problems or issues, define
criteria and standards, collect data ,compare performance with criteria and
standards, implement change and reaudit: sustaining improvements.

21
 FURTHER EVENTS
Two weeks later, Alex returned to school.
He used every opportunity trying to show his friends the scar from the
surgery and talk about medical
devices, that he had seen in the hospital.
His little brother was happy that they are now all together.
Sometimes he was capricious and cried especially when Mom went to work,
leaving him with his nanny.
The situation with Alex forces mother to reflect about the priorities of the
house \ work.
She asked her husband to find a job closer to home, in order to be close to
family.
“For me is hard to deal with everything, especially when our second child was
born. Look what happened
with Alex, little oversight from my part, when I could not talk to the doctor
properly and it ended with the surgery.
Even though I took a week at my own expense and I skipped important
things to do at work, this does not work
properly. As a result, we all suffered: kids, ourselves, work”.
“Yes, something must be done ...” said father. “I think you need to find a
babysitter with a in-house living”.
The doctor wrote the following reflection at the appraisal.

QUESTION:
Q36: WHAT IS Appraisal?
Appraisal is a process of facilitated self-review supported by information
gathered from the full scope of a doctor's work. It is a protected time, once a
year, for each doctor to focus, with a trained colleague, on their scope of work.

22
 Conclusion:
Alex Pam is an 8 years old boy, who brought to Emergency by his mom and
little brother, his initial signs of flushed face, sunken eyes and stomach ache.
Dr.timoff examined Alex, and took a history of Alex to fund out that the pain
started earlier that morning, Alex was vomiting, the was is located at right
the bottom of the stomach, Alex earlier caught a cold and had a sore throat
in the past 48 hours, he was given paracetamol, the outcome of the physical
examination was that There are: a moderate pain in the right iliac fossa;
painful stomach during coughing; active bowel sounds; normal hernial
opening .
Rectal examination is not performed. Alex provides a concentrated urine.
Alex was hospitalized, and waited for his test results, in the morning Dr.
Semens preformed a surgery for Alex to check his appendix to find out it’s
pale, with a slight pink color, after that Dr. Torrent performs a minor surgery
for Alex, intravenous morphine was given in order to relief pain, afterwards
Alex is admitted to the post-surgery ward, Dr. Semens comes to check up on
Alex and discuss his case with his mom where express that the results do not
confirm appendicitis but rather indicates mesadenitis ( mesenteric adenitis),
Alex seems to be misdiagnosed initially but it was later discovered his correct
diagnose both of them have similar symptoms, two weeks later Alex returns
to his normal life, his parents are trying to put more effort into being close to
there kids.

23
 Final diagnosis:

Mesenteric
Lymphadenitis

#Also known as mesenteric adenitis

Inflammation of mesenteric lymph nodes

24
 References:
BOOKS:

❖ Moore - Clinically Oriented Anatomy 7th Ed

❖ Guyton and Hall Textbook of Medical Physiology 12th Edition
❖ Physiology Fourth Edition Linda S. Costanzo, PhD
❖ Robbins Basic Pathology - Vinay Kumar (2017)
❖ Pathoma 2021 PDF
❖ Lippincott Illustrated Reviews: Pharmacology Sixth Edition
❖ a LANGE medical book Katzung & Trevor’s Pharmacology
❖ STEP-UP to MEDICINE FOURTH EDITION
❖ Lynn S. Bickley - Bates’ Guide to Physical Examination and History Taking
- 12th Edition
❖ Bates' Pocket Guide to Physical Examination and History Taking

WEBSITES :

❖ 16. Abdominal pain in childhood. Diagnostic tests and differential

diagnosis. – greek.doctor
❖ Paracetamol for children (including Calpol): painkiller for headaches,
stomach ache and to treat high temperature - NHS (www.nhs.uk)
❖ Paracetamol (Acetaminophen): mechanisms of action - ANDERSON -
2008 - Pediatric Anesthesia - Wiley Online Library
❖ RLO: The Kidneys and Drug Excretion (nottingham.ac.uk)
❖ Your body’s ADME process when you take medication (singlecare.com)
❖ https://www.ncbi.nlm.nih.gov/books/NBK459220/
❖ Abdominal Exam - StatPearls - NCBI Bookshelf (nih.gov)
❖ https://www.msdmanuals.com/home/lung-and-airway-
disorders/biology-of-the-lungs-and-airways/exchanging-oxygen-and-
carbon-
dioxide#:~:text=Gas%20exchange%20takes%20place%20in,the%20air%2
0in%20the%20alveoli.
❖ https://www.ncbi.nlm.nih.gov/books/NBK279250/#:~:text=Blood%20cir
culation%20starts%20when%20the,chambers)%2C%20which%20then%2
0expand.
❖ https://www.ck12.org/book/human-biology-circulation/section/5.1/

25