CASE REPORT

Tuesday, October 15th 2013

Team on duty : Dr. Andria S Dr. JokoS Dr. Guruh Laut Dr. Aa. Ahmad Dr. Tommy I. Patient identity Name : Wulandari Lisna Age : 17 years old Sex : Female Address : Desa Lambhuk, Kec. Ulee Kareng ,Kota Banda Aceh CM : 94 21 00 Phone : 085260064643 Chief complain Pain at the right lower abdomen Patient illnes history The patient consult from obstetry division with a chief complain pain at the right lower abdomen for 1 days. Initially, patient felt pain at epigastric region and then pain was felt at the lower right abdomen. There was no history of fever. There was history of nausea and vomiting was present. There was no abnormality in urinate and defecation. History of pregnancy 13 weeks. Physical examination Vital sign : Blood pressure Pulse Respiratory rates Body temperature

II.

III.

IV.

: 112/80 mmHg : 96 beats/min : 20 breaths/min : 36,2 oC

L/S at the right lower abdominal region : I : Symmetrical, distension (-) A: Bowel sound (+) P: Pain (+), Mc.Burney sign (+). P: Tympani (+) Rectal examination : Spinchter Ani Ampula Recti Mucosa Recti Pain

: Tight : Feces (+) : Smooth : (+)

Gloove V

: Blood (-), Feces (+).

Assessments: Susp. Acute Appendicitis + G1P0A0 13 weeks Management Stop oral intake IVFD RL 20 drips / minute Inj. Cefotaxime 1 gr Laboratory examination Radiologic examination Laboratory examination Hb White blood count Platelet Ht Blood glucose adrandom CT / BT Plano test

VI

VII

: 10,3 gr/dl : 6.000 /ul : 315.000 /ul : 28 % : 134 mg/dl : 7` /2` : (+)

VIII

Radiology examination USG abdomen : Gravid intra uterine 13-14 weeks Acute Appendicitis Diagnose Acute Appendicitis + G1P0A0 13 weeks Consult to digestive division Preparation for appendectomy emergency Consult to OBGIN division Cygest before operation Back up Intraoperatif

IX.

X.

XI.

Intra operative Patient in supine position with Spinal anasthesia Aseptic and antiseptic procedure Performed skincrease incision Deeper incision cutis, sub cutis, fascia until peritoneum Identified caecum and appendix There was appendix with antecaecal position, erectil, without perforated, length 9 cm, diameter 1 cm Appendix release from mesoappendix

 Performed appendectomy and double ligation suture Operation wound was rinsed with warm gauze normal saline until surely clean. Operation wound was closed by primary sutured

XII

Post op Diagnose Acute appendicitis + pregnancy 13 weeks (ICD-10-CM K35.80)

XIII Date
19-102013 POD III

Follow up S O
Vital Sign : General condition: good BP : 120/80 mmHg RR : 18 breaths/mnt Pulse : 78 beats/mnt L/S at the right lower abdominal region : I : Simetrical P: Soepel, pain (-) P: Tympani (+) A: Bowel sound (+)

A
Acute appendicitis + pregnancy 13 weeks (ICD10-CM K35.80)

P Out of clinic patient