CASE REPORT Thursday,April 3rd 2014 Team of duty: dr. Hendra Kastiaji dr. M. Nazir Tam unan dr.

!ynaldi Andriansya dr. Khali" dr. #umrahadi dr. $auhari dr. Muharriansyah I. Patient identity: Name A%e #e) Address &h(ne Num er M! &atient -ame at : : : : : : : A%un% &erdana 2' years (ld Male $l *aha%ia N(.+ ,a"sana, Ke-. Kuta Alam, *anda A-eh 0+211213.120 ..'/1. 00.00 &M

II. III.

Chief complaint &ain at the ri%ht l(1er a d(minal re%i(n Presenting history &atient -ame t( 2ain(el A idin 3mer%en-y !((m 1ith -hie4 -(mplaint pain at the ri%ht l(1er a d(minal re%i(n sin-e / days a%(. 5irstly, patient 4ell pain at epi%astri- re%i(n and then pain 1as spread at the ri%ht l(1er a d(men, and e-ame 1(rst sin-e 4 days a%(. Nausea and 6(mitin% 1as present. Hist(ry (4 ta"in% medi-ine 7anal%eti-8 798 Physical e amination: :ital #i%n ;(ns-i(usness : Alert *l((d &ressure : 110</0 mmH% &ulse : +0 eats< min !! : 20 reaths<min T re-tal : 3/ = ; ,<# at the l(1er ri%ht a d(minal re%i(n : > : #ymmetri-ally, distenti(n 7?8 A: *(1el s(und 798 & : &ain 798 at the ri%ht l(1er a d(minal re%i(n, mus-ular ri%idity 798 & : Thympani 798, li6er dullness 798

IV.

@i%ital re-tal e)aminati(n : T(nus #pin-hter Ani !e-ti Ampulla !e-ti Mu-(us &ain Al(6e V. VI. Assessment: #usp appendi-itis per4(rati(n !anagement: #t(p (ral inta"e >:5@ !, 20 drips<minute Brinary ;atheter >nj ;e4tria)(ne 1 %r >nj Metamiz(l #(dium 1 %r ,a (rat(ry e)aminati(n "a#oratory result: H Chite l((d -(unt &latelet Ht ;T *T Br ;r *l((d %lu-(se ad rand(m $iagnose Appendi-itis per4(rati(n

: Ti%ht : 3mpty : #m((th : &ain 798 : *l((d 7?8, 5e-es 7?8.

VII. VI. I%. %.

: : : : : : : : :

10 %r<dl 10.000 <ul 301.000 <ul 40 D 10 minute ' minute 30 m%<dl 0,. m%<dl 102 m%<dl

Consult to digesti&e surgery di&ision Appende-t(my emer%en-y Operati&e report &atient in supine p(siti(n 1ith %eneral anasthesia Asepti-, Antisepti- pr(-edure and drappin% pr(-edure &er4(rmed Arid >r(n in-isi(n >n-isi(n 1as deepened layer y layer until perit(neum Chen the perit(neum 1as (pened -(me (ut ser(us purulent 4luid E 10 -&er4(rmed e)pl(rati(n t( -ae-um and identi4ied appendi) ante-ae-al, ere-til, edema, per4(rated at the -(rpus (4 appendi), hyperemi-, len%th ' -m F 1 -m. Appendi) 1as release 4r(m mes(appendi) and leedin% -(ntr(lled. &er4(rmed appende-t(my and d(u le li%ati(n suture

 %II.

#tump appendi) per4(rmed t( hist(pat(l(%i- e)aminati(n A d(minal -a6ity 1as irri%ated a%ain 1ith 1arm n(rmal saline until -lear Gperati(n 1(und -l(sed y primary suture Post operati&e $iagnosed Appendi-itis per4(rati(n 7>;@ 10 ;M K30.28
S &ain 798 O :ital si%n *l((d &ressure : 120<+0 mmh% &ulse : +4 eats<mnt !! : 20 reaths<mnt Brin (utput : #<, at the a d(minal re%i(n : >: #ymmetri-al, distenti(n 7?8 A: *(1el s(und 798 &: &ain 7?8 &: Thympani A P >:5@ !, 20 drip<minute >nj. ;e4tria)(ne 1 %r<12 h(ur >nj. Metamiz(le s(dium 1 %r< + h(ur @iet 1+00 "-al

%III. 'ollo( up:

$ate /?04? 14 &G@ >>>

Appendi-itis per4(rati(n 7>;@ 10 ;M K30.28