A/F/26 yo

69.09.74
Chief Complaint : pain on right lower abdomen
It has been suffered since one day before admission. Initially, pain
was felt on the epigastrium 3 days ago. Fever (+) since three days
ago, nausea (+), vomiting (+) every patient took meal.
History of using pain killer drugs (-), micturation (+) normal,
defecation (+) normal.
Menstrual cycle was in normal limit. History of trauma (-)

Present state :
Awareness : Alert
TD : 110/70 mmHg
HR : 84 x/i
RR : 22 x/i
T : 38.0 °C
VAS scale :6
Generalized State

Head and neck : no abnormality

Chest : no abnormality
Abdomen : in localized state
Genitalia : Female, no abnormality
Extremities : no abnormality
Localized state :
Abdomen :
• I : symmetric, distention (-)
• P : pain (+) on right lower abdomen, McBurney
Sign (+), Blumberg’s sign (+), Rovsing’s sign (+),
muscular rigidity (-).
• P : liver dullness (+), tympani (+)
• A : peristaltic (+)
Digital rectal Examination:

Perineum usual, tight anal tone sphincter, slippery

mucosa, pressure pain (+), rectum was not
collapsed, gloves : feces (-), blood (-) mucous (-)
Laboratory findings:
•Hb / Ht / WBC / PLT : 14,5 / 42 / 20,29 / 214
•Na / K / Cl : 140 / 3,9 / 100
•Random Blood Glucose : 124
•Urinalysis : within normal limit
Working Diagnosis: Acute Appendicitis

Management
• Fasting
• Installation of IVFD with cristalloid fluid
• Insertion Foley Catheter
• Inj. Antibiotics
• Inj. Analgetics
• Prepare for appendectomy
Management in Operation Theatre
• Patient in supine position, under General anaesthesia ETT, aseptic,
antiseptic
• midline incision, cutis, subcutis, fascia was opened, peritoneum was
opened.
• Omentum directed to right fossa iliaca, insertion of moist gauge to
redirect omentum to craniomedial direction.
• Identification of caecum, appendix was in antecaecal with size 13x1,5cm.
The appendix was gangrenous on the tip.
• Appendix and mesoappendix were split, ligation of artery appendicularis.
• Appendectomy was perfomed with double ligation.
• The abdomen cavity was cleaned with moist gauze
• The surgical wound was closed layer by layer
• Appendix content was fecalith
• Operation finish