STAGNAN PATIENTS

No Name/ Age Diagnosis Assessment Last condition

Medical record

1. Gregorio 5 yo Appendisitis acute Pro Laparotomy Operation

M./1116933 appendectomy
fasting,
-IVFD KaeN 3B 1500cc+ 10
meq KCl /24 hr,
- ceftriaxone 2x400 mg IV,
-Paracetamol 4x 160 mg IV,
observation of fluid balance
and haemodynamic state per
hour.
1st Operation
Name : child Gregorio M.
Age : 5 y.o
Date of Birth : 03/05/2011
Sex : male
Occupation : Student
No. MR : 01116833
Anamnesis
Chief Complant: Pain in the right lower
abdomen since 1 day before admission.
Recent history:
Pain in the Right lower abdomen since 1 day befor
admission. Pain increased with leg movement ,
Pain didnt spread to another area of abdomen.
Vomit 2 x (+), nausea (+), fever (+). Defecation &
urination normal. Last defecation 1 day before
admission.
Physical Examination
BW: 16 kg BH: 90 cm
BP:- HR:104 x , RR: 18 x . T: 36.9 C
General Status: moderately ill
GCS: E4 M6 V5 = 15, compos mentis.
Eye: conjungtiva anemis(-/-)
Nose: deformity (-)
Neck: Enlargement of lymph node (-)
Thorax:
Lungs: symmetric at static and dynamic breathing, vesiculer(+ /+), rales
(-/-), wheezing (-/-)
Heart: S1 S2 normal, regular rhythm
Abdomen: flat, bowel sound (+) normal, tenderness (+), pain in McBurney
point (+). muscular defence(-)
Extremity : warm, oedema (-)
Laboratory Examination

examinati result examinati result

on on
Hb 14.8 g/dl SGOT 34 U/l
Ht 42 % SGPT 13 U/I
WBC count 13.9 ribu/ul Ur 23 mg/dl
Platelets 296 ribu/ul Cr 0.4 mg/dl
RBC 5.02 juta/ul PT 14.7(13.6)
APTT 35.7(30.7)
RBG 70
Na 136 mmol/I
K 4.08 mmol/I
Cl 100 mmol/I
Radiology - CXR
Lung and heart in the normal range
Diagnosis
Acute appendicisitis
Planning
Pro appendictomy
IVFD RL 500 ccKaEN 3B 1300 cc +10 meq KCl /24
hr
cefotaxime 2x400 mg
Paracetamol 4x160 mg
Catheter urin
Operation Report
Patient is in supine position under general anesthesia
A and antisepsis of the operation field
Incision tranverally as high as McBurney through cutis, subcutis,
fascia, muscle. When peritoneum was opened, there was pus +/- 10cc
and suctioned
looks omentum taksis to bottom right, difficult to identification
secum, decided to make wider incision to lateral and medial
When identification secum, appendix was retrocaecal
intraperitoneum adhere to around tissue., performed adhesiolisis
with warm steril water. Identification appendix, 6x2x1 cm, theres
perforated at 1/3 proksimal appendiks, oedema (+), redness (+),
fecoltih (+).
Performed appendektomi, and countinue with double ligation
Care the bleeding
Wash with warm and steril water
The operation wound was closed layer by layer
The operation done