15F STOMACH PAIN SINCE 5 MTHS

 

28/10/2026

THIS PATIENT DATA WAS GATHERED BY ROLL NO17, BATCH 2023 AS PART OF HER COMPETENCE BASED LEARNING EVALUATION PORTFOLIO PREPARATION

THIS IS THE CASE OF 15F WITH STOMACH PAIN 5 MTHS AGO, VOMITING, SEVERE STOMACH PAIN 5 DAYS BACK AND FEVER SINCE 4 DAYS

*Date:* 28/10/2026

*Age/Sex:* 15/F

*Chief Complaints:*

- Stomach pain - 5 months ago

- Severe stomach pain - 5 days back

- Vomiting - 5 days back

- Fever - 4 days back

*HOPI:*

Pt was apparently asymptomatic 5 months ago. Later she developed stomach pain which was dull around umbilical area. On 23rd Oct she developed dull, vague pain around umbilicus and then became sharp and more severe and radiated to right iliac fossa.

Pain was aggravated with movement.

She also developed vomitings water as content, 4-5 episodes/day, Non-bilious, Non-Projectile.

H/o Fever which is Low grade, not associated c chills.

She underwent Appendicitis surgery on 24th Oct.

*Past H/O:* N/K/C/O DM, HTN, Epilepsy, Asthma

*Personal H/O:*

- Diet - Mixed, Low fiber diet

- Appetite - Decreased

- Bowel - Irregular, Once in 2 days

- Bladder - Regular

- Sleep - Sound

Addictions - None

                                           

General Examination - Pt is c/c/c well oriented to t/p/p

P I C C L E

(-)

*Systemic Examination -*

- CVS - S1 S2 (+)

- RS - NVBS B/L

- CNS - NFD

- PA - Inspection - All quadrants moving together with respiration.

  No visible pulsations

  No Engorged veins.

*Ochsner-Sherren Regimen:*

1. Admission

2. Nil by Mouth (NPO)

3. IV fluids

4. Antibiotics - Ceftriaxone + Metronidazole (or)

   for enteric gram -ve organisms Amoxicillin + clavulanate

5. Analgesics and Antiemetics

6. Observation (4th hrly) Temp & PR

7. Imaging and reassessment

Follow up - Patient was discharged in stable condition. She reports improvement in abdominal pain, is tolerating oral feeds and is passing urine normally. No history of fever, vomiting or abdominal pain.

Here is a set of targeted, Socratic questions designed to guide medical students through the clinical reasoning, pathophysiology, and surgical decision-making behind this case of a **15-year-old female presenting with chronic-to-acute abdominal pain**.

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### Phase 1: History of Present Illness (HPI) & Symptom Evolution

* **Translating Chronicity:** The patient reports dull umbilical pain starting **5 months ago**, which acutely shifted and localized to the **right iliac fossa (RIF)** 5 days prior alongside vomiting and low-grade fever. How does the classic visceral-to-somatic pain transition (referred visceral pain from the midgut turning into localized parietal peritoneal irritation) explain this timeline?

* **Uncovering Clues:** The personal history notes a **low-fiber, mixed diet and infrequent bowel habits (once every 2 days)**. Could chronic functional constipation or low-fiber intake contribute to appendiceal luminal stasis or fecalith formation over months? Why or why not?

* **Symptom Clustering:** How do non-bilious, non-projectile vomiting episodes that emerge days into an acute exacerbation fit into the pathophysiology of acute appendicitis versus other acute abdominal pathologies?

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### Phase 2: Clinical Examination & Localization

* **Anatomical Localization:** When the pain migrated from a vague periumbilical sensation to the RIF and was aggravated by movement, what peritoneal signs (e.g., Rovsing's, Psoas, Obturator, or direct rebound tenderness) would you specifically look for on physical examination to confirm appendiceal inflammation?

* **Differential Anchoring:** Although the patient ultimately underwent an appendectomy, what other adolescent lower-right quadrant differentials (such as mesenteric adenitis, Meckel's diverticulitis, or pelvic inflammatory disease in a female patient) must be kept in mind during the initial evaluation?

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### Phase 3: Management & Post-Operative Care

* **Surgical Principles:** The case mentions the implementation of the **Ochsner-Sherren regimen** in the notes (though the patient ultimately underwent appendicitis surgery on 24th Oct). What is the historical and clinical purpose of the Ochsner-Sherren regimen, and in what specific scenario (e.g., an appendix mass vs. early acute appendicitis) is conservative management versus immediate appendectomy indicated?

* **Pharmacotherapy Rationale:** The documented medical management mentions broad-spectrum coverage such as Ceftriaxone combined with Metronidazole (or Amoxicillin-Clavulanate). What is the rationale for covering both aerobic gram-negative bacilli and anaerobic flora (like *Bacteroides fragilis*) in acute appendicitis?

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### Phase 4: Clinical Reflection & Outcomes

* **Post-Op Reassessment:** Upon discharge, the patient reported normal passage of urine, tolerating oral feeds, and resolution of pain and fever. Which physiological milestones are most critical to confirm prior to clearing a post-operative appendectomy patient for discharge?