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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