Courseworks Appendicitis


Appendicitis

 
  1. Most common aetiology of acute appendicitis is idiopathic.
  2. Most common site of gangrenous appendix is TIP.
  3. Most common site of perforation base.
  4. Appendocolith associated with 90% of acute appendicitis.
  5. History: The classic history of anorexia and periumbilical pain followed by nausea, right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases.
  6. Migration of pain from the periumbilical area to the RLQ is the most discriminating historical feature. When vomiting occurs, it nearly always follows the onset of pain.
  7. Physical: RLQ tenderness is present in 96% of patients but is a very nonspecific finding.
  8. The most specific physical findings are rebound tenderness, pain on percussion, rigidity, and guarding.
  9. Sign of acute appendicitis: 
Dunphy’s SignPain on coughing
Rovsing’s signPain in the right lower quadrant during palpation of the left lower quadrant
Obturator sign- Pain on internal rotation of the hip
- Suggestive of pelvic appendix
Iliopsoas sign- Pain on extension of the right hip
- Suggestive of retrocecal appendix
Ponting Sign- Patient point pain to the right iliac fossa.
  1. Lab Studies:
    1. Complete blood count: 80-85% of adults with appendicitis have a WBC count greater than 10,000 and Neutrophilia greater than 75%.
    2. C-reactive protein: C-reactive protein (CRP) is an acute-phase reactant synthesized by the liver in response to bacterial infection.
    3.  Serum levels begin to rise within 6-12 hours of acute tissue inflammation. a normal CRP has a negative predictive value of approximately 100% for the presence of appendicitis.
  2. Imaging Studies:
    1. Computed tomography scan  - diagnostic test of choice.
    2. Ultrasound:  An outer diameter of greater than 6 mm, noncompressibility, lack of peristalsis, or presence of  a periappendiceal fluid collection characterizes an inflamed appendix.
    3. The normal appendix is not visualized in most cases. 
  1. Alvarado’s score (Scoring system for appendicitis is called Alvarado (MANTRELS scoring system).
Symptoms –
  1. Migrating RIF pain – 1                        
  2. Anorexia – 1                                    
  3. Nausea and vomiting - 1
Sign –
  1. RIF tendemed   - 2                                              
  2. Rebound tendemcy – 1                
  3. Fever - 1
Lab –
  1. Leucocytosis -2                                   
  2. Shift to left – 1                                
Total score = 10

Prediction of Appendicitis based on Alvarado score
ScoresPrediction
9-10Appendicitis is certain
7-8High likelihood of appendicitis
5-6Equivocal
1-4Appendicitis can be ruled out
  1. Abdominal x-rays: Visualization of an appendicolith in a patient with symptoms consistent with appendicitis is highly suggestive, but this occurs in < 10% of cases. 
  2. Radionuclide scanning: Whole blood is withdrawn. Neutrophils and macrophages are labeled with technetium 99m albumin and administered intravenously. 
  3. Images of the abdomen and pelvis are obtained serially over 4 hours. Localized uptake of tracer in the RLQ suggests appendiceal inflammation. 
  1. Treatment
    1. Open or laparoscopic appendectomy when no lump formation is there:- (Presentation within 72 hrs)
    2. When lump is form (>72 hrs) – Oshnner sherren regimen is the treatment of choice. Which include
      1. Nill per oral          
      2. IV fluid
      3. Antibiotics for 3-4 days
      4. Elective appendisectomy after 4-6 weeks.
    3. Incision we can use for open appendisectomy –     
      1. Grid iron
      2. Ruther ford Morrison incision.
      3. Lanz incision.   
Abdominal Examination Signs
SignDescriptionDiagnosis
Aaron signPain or pressure in epigastrium persistent firm pressure applied to McBurney's pointAcute appendicitis
Bassler signSharp pain created by compressing appendix between abdominal wall and iliacus  Chronic appendicitis
Blumberg's signTransient abdominal wall rebound tendernessPeritoneal inflammation
Carnett's signLoss of abdominal tenderness when abdominal wall muscles are contracted                  Intra-abdominal source of   abdominal pain
Chandelier signExtreme lower abdominal and pelvic pain with movement of cervix    Pelvic inflammatory disease
Claybrook signAccentuation of breath and cardiac sounds through abdominal wallRuptured abdominal viscus
Courvoisier's signPalpable gallbladder in presence of painless jaundicePeriampullary tumor
Cruveilhier signVaricose veins at umbilicus (caput medusae)Portal hypertension
Danforth signShoulder pain on inspirationHemoperitoneum
Fothergill's signAbdominal wall mass that does not cross midline and remains palpable when rectus contractedRectus muscle hematomas
 
Mannkopf's signIncreased pulse when painful abdomen palpatedAbsent if malingering
Ransohoff signYellow discoloration of umbilical regionRuptured CBD
Ten Horn signPain caused by gentle traction of right testicleAcute appendicitis
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Appendix M to Part 121 - Airplane Flight Recorder Specifications

The recorded values must meet the designated range, resolution and accuracy requirements during static and dynamic conditions. Dynamic condition means the parameter is experiencing change at the maximum rate attainable, including the maximum rate of reversal. All data recorded must be correlated in time to within one second.

Parameters Range Accuracy (sensor input) Seconds per sampling interval Resolution Remarks
1. Time or relative times counts. 124 Hrs, 0 to 4095±0.125% per hour41 secUTC time preferred when available. Count increments each 4 seconds of system operation.
2. Pressure Altitude−1000 ft to max certificated altitude of aircraft. + 5000 ft±100 to ±700 ft (see table, TSO C124a or TSO C51a)15′ to 35′Data should be obtained from the air data computer when practicable.
3. Indicated airspeed or Calibrated airspeed50 KIAS or minimum value to Max Vso to 1.2 V. D±5% and ±3%11 ktData should be obtained from the air data computer when practicable.
4. Heading (Primary flight crew reference)0-360° and Discrete “true” or “mag”±2°10.5°When true or magnetic heading can be selected as the primary heading reference, a discrete indicating selection must be recorded.
5. Normal acceleration (vertical) 9−3g to + 6g±1% of max range excluding datum error of ±5%0.1250.004g
6. Pitch Attitude±75°±2°1 or 0.25 for airplanes operated under 0.5°A sampling rate of 0.25 is recommended.
7. Roll attitude 2±180°±2°1 or 0.5 for airplanes operated under 0.5A sampling rate of 0.5 is recommended.
8. Manual Radio Transmitter Keying or CVR/DFDR synchronization referenceOn-Off (Discrete)
None
1Preferably each crew member but one discrete acceptable for all transmission provided the CVR/FDR system complies with TSO C124a CVR synchronization requirements (paragraph 4.2.1 ED-55).
9. Thrust/power on each engine - primary flight crew referenceFull range forward±2%1 (per engine)0.3% of full rangeSufficient parameters (e.g. EPR, N1 or Torque, NP) as appropriate to the particular engine being recorded to determine power in forward and reverse thrust, including potential overspeed condition.
10. Autopilot EngagementDiscrete “on” or “off”1
11. Longitudinal Acceleration±1g±1.5% max. range excluding datum error of ±5%0.250.004g
12a. Pitch control(s) position (nonfly-by-wire systems). 18Full Range±2° unless higher accuracy uniquely required0.5 or 0.25 for airplanes operated under 0.5% of full rangeFor airplanes that have a flight control breakaway capability that allows either pilot to operate the controls independently, record both control inputs. The control inputs may be sampled alternately once per second to produce the sampling interval of 0.5 or 0.25, as applicable.
12b. Pitch control(s) position (fly-by-wire systems). 3,18Full Range±2° unless higher accuracy uniquely required0.5 or 0.25 for airplanes operated under 0.2% of full range
13a. Lateral control position(s) (nonfly-by-wire). 18Full Range±2° unless higher accuracy uniquely required0.5 or 0.25 for airplanes operated under 0.2% of full rangeFor airplanes that have a flight control breakaway capability that allows either pilot to operate the controls independently, record both control inputs. The control inputs may be sampled alternately once per second to produce the sampling interval of 0.5 or 0.25, as applicable.
13b. Lateral control position(s) (fly-by-wire). 4,18Full Range±2° unless higher accuracy uniquely required0.5 or 0.25 for airplanes operated under 0.2% of full range.
14a. Yaw control position(s) (nonfly-by-wire). 5,18Full Range±2° unless higher accuracy uniquely required0.50.3% of full rangeFor airplanes that have a flight control breakaway capability that allows either pilot to operate the controls independently, record both control inputs. The control inputs may be sampled alternately once per second to produce the sampling interval of 0.5.
14b. Yaw control position(s) (fly-by-wire). 18Full Range±2° unless higher accuracy uniquely required0.50.2% of full range
15. Pitch control surface(s) position. 6,18Full Range±2° unless higher accuracy uniquely required0.5 or 0.25 for airplanes operated under 0.3% of full rangeFor airplanes fitted with multiple or split surfaces, a suitable combination of inputs is acceptable in lieu of recording each surface separately. The control surfaces may be sampled alternately once per second to produce the sampling interval of 0.5 or 0.25, as applicable.
16. Lateral control surface(s) position. 7,18Full Range±2° unless higher accuracy uniquely required0.5 or 0.25 for airplanes operated under 0.3% of full rangeA suitable combination of surface position sensors is acceptable in lieu of recording each surface separately. The control surfaces may be sampled alternately to produce the sampling interval of 0.5 or 0.25, as applicable.
17. Yaw control surface(s) position. 8,18Full Range±2° unless higher accuracy uniquely required0.50.2% of full rangeFor airplanes with multiple or split surfaces, a suitable combination of surface position sensors is acceptable in lieu of recording each surface separately. The control surfaces may be sampled alternately to produce the sampling interval of 0.5.
18. Lateral Acceleration±1g±1.5% max. range excluding datum error of ±5%0.250.004g
19. Pitch Trim Surface PositionFull Range±3° Unless Higher Accuracy Uniquely Required10.6% of full range
20. Trailing Edge Flap or Cockpit Control Selection. 10Full Range or Each Position (discrete)±3° or as Pilot's indicator20.5% of full rangeFlap position and cockpit control may each be sampled at 4 second intervals, to give a data point every 2 seconds.
21. Leading Edge Flap or Cockpit Control Selection. 11Full Range or Each Discrete Position±3° or as Pilot's indicator and sufficient to determine each discrete position20.5% of full rangeLeft and right sides, or flap position and cockpit control may each be sampled at 4 second intervals, so as to give a data point every 2 seconds.
22. Each Thrust Reverser Position (or equivalent for propeller airplane)Stowed, In Transit, and Reverse (Discrete)1 (per engine)Turbo-jet - 2 discretes enable the 3 states to be determined.
Turbo-prop - discrete.
23. Ground spoiler position or brake selection 12Full range or each position (discrete)±2° Unless higher accuracy uniquely required1 or 0.5 for airplanes operated under 0.5% of full range
24. Outside Air Temperature or Total Air Temperature. 13−50 °C to + 90 °C±2 °C20.3 °C
25. Autopilot/Autothrottle/AFCS Mode and Engagement StatusA suitable combination of discretes1Discretes should show which systems are engaged and which primary modes are controlling the flight path and speed of the aircraft.
26. Radio Altitude 14−20 ft to 2,500 ft±2 ft or ±3% whichever is greater below 500 ft and ±5% above 500 ft11 ft + 5% above 500 ftFor autoland/category 3 operations. Each radio altimeter should be recorded, but arranged so that at least one is recorded each second.
27. Localizer Deviation, MLS Azimuth, or GPS Latitude Deviation±400 Microamps or available sensor range as installed
±62°
As installed ±3% recommended10.3% of full rangeFor autoland/category 3 operations. Each system should be recorded but arranged so that at least one is recorded each second. It is not necessary to record ILS and MLS at the same time, only the approach aid in use need be recorded.
28. Glideslope Deviation, MLS Elevation, or GPS Vertical Deviation±400 Microamps or available sensor range as installed
0.9 to + 30°
As installed + /3−3% recommended10.3% of full rangeFor autoland/category 3 operations. Each system should be recorded but arranged so that at least one is recorded each second. It is not necessary to record ILS and MLS at the same time, only the approach aid in use need be recorded.
29. Marker Beacon PassageDiscrete “on” or “off”1A single discrete is acceptable for all markers.
30. Master WarningDiscrete1Record the master warning and record each “red” warning that cannot be determined from other parameters or from the cockpit voice recorder.
31. Air/ground sensor (primary airplane system reference nose or main gear)Discrete “air” or “ground”1 (0.25 recommended)
32. Angle of Attack (If measured directly)As installedAs installed2 or 0.5 for airplanes operated under 0.3% of full rangeIf left and right sensors are available, each may be recorded at 4 or 1 second intervals, as appropriate, so as to give a data point at 2 seconds or 0.5 second, as required.
33. Hydraulic Pressure Low, Each SystemDiscrete or available sensor range, “low” or “normal”±5%20.5% of full range
34. GroundspeedAs InstalledMost Accurate Systems Installed10.2% of full range
35. GPWS (ground proximity warning system)Discrete “warning” or “off”1A suitable combination of discretes unless recorder capacity is limited in which case a single discrete for all modes is acceptable.
36. Landing Gear Position or Landing gear cockpit control selectionDiscrete4A suitable combination of discretes should be recorded.
37. Drift Angle. 15As installedAs installed40.1°
38. Wind Speed and DirectionAs installedAs installed41 knot, and 1.0°
39. Latitude and LongitudeAs installedAs installed40.002°, or as installedProvided by the Primary Navigation System Reference. Where capacity permits Latitude/longitude resolution should be 0.0002°.
40. Stick shaker and pusher activationDiscrete(s) “on” or “off”1A suitable combination of discretes to determine activation.
41. Windshear DetectionDiscrete “warning” or “off”1
42. Throttle/power Leverl position. 16Full Range±2%1 for each lever2% of full rangeFor airplanes with non-mechanically linked cockpit engine controls.
43. Additional Engine ParametersAs installedAs installedEach engine each second2% of full rangeWhere capacity permits, the preferred priority is indicated vibration level, N2, EGT, Fuel Flow, Fuel Cut-off lever position and N3, unless engine manufacturer recommends otherwise.
44. Traffic Alert and Collision Avoidance System (TCAS)DiscretesAs installed1A suitable combination of discretes should be recorded to determine the status of - Combined Control, Vertical Control, Up Advisory, and Down Advisory. (ref. ARINC Characteristic 735 Attachment 6E, TCAS VERTICAL RA DATA OUTPUT WORD.)
45. DME 1 and 2 Distance0-200 NMAs installed41 NM1 mile
46. Nav 1 and 2 Selected FrequencyFull RangeAs installed4Sufficient to determine selected frequency
47. Selected barometric settingFull Range±5%(1 per 64 sec.)0.2% of full range
48. Selected AltitudeFull Range±5%1100 ft
49. Selected speedFull Range±5%11 knot
50. Selected MachFull Range±5%1.01
51. Selected vertical speedFull Range±5%1100 ft/min
52. Selected headingFull Range±5%1
53. Selected flight pathFull Range±5%1
54. Selected decision heightFull Range±5%641 ft
55. EFIS display formatDiscrete(s)4Discretes should show the display system status (e.g., off, normal, fail, composite, sector, plan, nav aids, weather radar, range, copy.
56. Multi-function/Engine Alerts Display formatDiscrete(s)4Discretes should show the display system status (e.g., off, normal, fail, and the identity of display pages for emergency procedures, need not be recorded.
57. Thrust command. 17Full Range±2%22% of full range
58. Thrust targetFull Range±2%42% of full range
59. Fuel quantity in CG trim tankFull Range±5%(1 per 64 sec.)1% of full range
60. Primary Navigation System ReferenceDiscrete GPS, INS, VOR/DME, MLS, Localizer Glideslope4A suitable combination of discretes to determine the Primary Navigation System reference.
61. Ice DetectionDiscrete “ice” or “no ice”4
62. Engine warning each engine vibrationDiscrete1
63. Engine warning each engine over tempDiscrete1
64. Engine warning each engine oil pressure lowDiscrete1
65. Engine warning each engine over speedDiscrete1
66. Yaw Trim Surface PositionFull Range±3% Unless Higher Accuracy Uniquely Required20.3% of full range
67. Roll Trim Surface PositionFull Range±3% Unless Higher Accuracy Uniquely Required20.3% of full range
68. Brake Pressure (left and right)As installed±5%1To determine braking effort applied by pilots or by autobrakes.
69. Brake Pedal Application (left and right)Discrete or Analog “applied” or “off”±5% (Analog)1To determine braking applied by pilots.
70. Yaw or sideslip angleFull Range±5%10.5°
71. Engine bleed valve positionDiscrete “open” or “closed”4
72. De-icing or anti-icing system selectionDiscrete “on” or “off”4
73. Computed center of gravityFull Range±5%(1 per 64 sec.)1% of full range
74. AC electrical bus statusDiscrete “power” or “off”4Each bus.
75. DC electrical bus statusDiscrete “power” or “off”4Each bus.
76 APU bleed valve positionDiscrete “open” or “closed”4
77. Hydraulic Pressure (each system)Full range±5%2100 psi
78. Loss of cabin pressureDiscrete “loss” or “normal”1
79. Computer failure (critical flight and engine control systems)Discrete “fail” or “normal”4
80. Heads-up display (when an information source is installed)Discrete(s) “on” or “off”4
81. Para-visual display (when an information source is installed)Discrete(s) “on” or “off”
82. Cockpit trim control input position - pitchFull Range±5%10.2% of full rangeWhere mechanical means for control inputs are not available, cockpit display trim positions should be recorded.
83. Cockpit trim control input position - rollFull Range±5%10.7% of full rangeWhere mechanical means for control inputs are not available, cockpit display trim position should be recorded.
84. Cockpit trim control input position - yawFull range±5%10.3% of full rangeWhere mechanical means for control input are not available, cockpit display trim positions should be recorded.
85. Trailing edge flap and cockpit flap control positionFull Range±5%20.5% of full rangeTrailing edge flaps and cockpit flap control position may each be sampled alternately at 4 second intervals to provide a sample each 0.5 second.
86. Leading edge flap and cockpit flap control positionFull Range or Discrete±5%10.5% of full range
87. Ground spoiler position and speed brake selectionFull range or discrete±5%0.50.3% of full range
88. All cockpit flight control input forces (control wheel, control column, rudder pedal) 18 19Full range
Control wheel ±70 lbs
Control column ±85 lbs
Rudder pedal ±165 lbs
±5%10.3% of full rangeFor fly-by-wire flight control systems, where flight control surface position is a function of the displacement of the control input device only, it is not necessary to record this parameter. For airplanes that have a flight control break away capability that allows either pilot to operate the control independently, record both control force inputs. The control force inputs may be sampled alternately once per 2 seconds to produce the sampling interval of 1.
89. Yaw damper statusDiscrete (on/off)0.5
90. Yaw damper commandFull rangeAs installed0.51% of full range
91. Standby rudder valve statusDiscrete0.5

[Doc. No. 28109, 62 FR 38382, July 17, 1997; 62 FR 48135, Sept. 12, 1997, as amended by Amdt. 121-271, 64 FR 46120, Aug. 24, 1999; Amdt. 121-278, 65 FR 51745, Aug. 24, 2000; 65 FR 81733, Dec. 27, 2000; Amdt. 121-292, 67 FR 54323, Aug. 21, 2002; Amdt. 121-300, 68 FR 42936, July 18, 2003; 68 FR 50069, Aug. 20, 2003; 68 FR 53877, Sept. 15, 2003; 70 FR 41134, July 18, 2005; Amdt. 125-54, 73 FR 12566, Mar. 7, 2008; Amdt. 121-338, 73 FR 12566, Mar. 7, 2008; Amdt. 121-342, 73 FR 73179, Dec. 2, 2008; Amdt. 121-349, 75 FR 17046, Apr. 5, 2010; Amdt. 121-347, 75 FR 7356, Feb. 19, 2010; Amdt. 121-364, 78 FR 39971, July 3, 2013; Docket FAA-2017-0733, Amdt. 121-379, 82 FR 34398, July 25, 2017]

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