EMERGENCY CASE REPORTS

Thursday, September 19th, 2013

SURGERY DEPARTMENT

EMERGENCY ROOMEMERGENCY ROOMWAHIDIN WAHIDIN

SUDIROHUSODO SUDIROHUSODO GENERAL HOSPITALGENERAL HOSPITAL

MAKASSARMAKASSAR

Thursday, September 19th, 2013

AmbulationAmbulation :: -- PatientsPatients

Hospitalized Hospitalized :: 44 patientspatients

ObservationObservation :: -- PatientPatient

OperatedOperated :: 11 PatientsPatients

DeathDeath :: PatientPatient

TotalTotal :: 44 patientspatients

No. 1Name : Mr. S Sex : MaleAge : 25 years old No. Reg : 628902

Chief complaint : Right lower abdominal painHistory taking : The pain had been apparent for 1 day. The pain started in

the central abdomen and has now become constant and has shifted to the right lower abdomen. the patient has vomited twice today. There were event of fever for 1 day.

Defecation : NormallyMicturation : Normally

Physical Examination

General Conditions:

Moderate Moderate illness/well nourish/composmentisillness/well nourish/composmentis

Vital sign:

BP : 11BP : 1100/7/700 mmHg mmHgPR : 80x/mnt, regular, adequate.PR : 80x/mnt, regular, adequate.RR : 20x/mnt.RR : 20x/mnt.T(Ax) : 38,3 °CT(Ax) : 38,3 °C

PHYSICAL EXAMINATIONPHYSICAL EXAMINATIONAbdomenAbdomen

I : Flat. Follow breath motion, , no bowel contour, no bowel motion. No tumor mass

A : Bowel sound normally

P : Localized tenderness (-). Defans muscular (-). Mc Burney pain (+). Rovsing sign (-), Blumberg sign (-)

P : Tympani, tapping pain (+)

Digital Rectal Examination

Sphincter ani was tight, Mucous was smooth, Ampula was empty

Gloves : Faeces (-), blood (-), slime (-)

Laboratory ResultLaboratory ResultWBC : 17,48 x 103 /μL

RBC : 5,5 x 106/μL

HGB : 16,8 g/dL

HCT : 45,5 %

PLT : 197 x 103/μL

CT / BT : 7’00”/3’00”

Blood Sugar : 96 mg/dl

Ureum : 17 mg/dl

Creatinin : 0,8 mg/dl

SGOT/SGPT : 20/14 u/l

Kalesaran Score Labeda ScoreMual +7 +4

Muntah +11 +2Demam +7 +7

Nyeri Batuk +15 +4Nyeri Ketok +5 +10Defans lokal -13 -11Leukositosis +15 +6

Gender +13TOTAL +47 +35

Interpretasi Kalesaran score Labeda Score

Operated > 19 > - 11

Observation - 15 s.d 19 -57 s.d -11

Not Appendicitis < -15 < -57

WORKING DIAGNOSIS : Acute appendicitis

MANAGEMENT : IVFD Medicaments Consult to Senior Digestive Surgeon advice : immediate appendectomy

OPERATION PROCEDURE Patient lied in supine position with GA Disinfection and draping procedure Performed grid iron incision, deepen until peritoneum Performed exploration, seen appendix phlegmonosa at retro caecal Performed retrograde appendectomy continue with purse string Bleeding control Close the wound layer by layer Done

POST OP DIAGNOSIS : Catharralis Appendicitis

PROGNOSIS

FOLLOW UP

Good

Vital Sign Acute abdomen