I/M/23yo

Chief Complaint : Pain on the right lower abdomen

It has been suffered by the patient since 1 day before

admitted to USU Hospital. The pain was initially felt on
the epigastrium of abdomen then migrated to the right
lower abdomen. Anorexia, nausea and vomiting was
found. History of fever was not found. History of
micturition and defecation was normal. History of
received massage in the abdomen and previous trauma
was not found.
 Present state:
• Awareness : Alert
• BP : 110/90 mmHg
• HR : 88 bpm
• RR : 20 times/minute
• T : 36.8°C
• VAS :5
 Generalized State :
Head and neck : No abnormality was found
Chest : No abnormality was found
Abdomen : In localized state
Genitalia : Male, No abnormality was found
Extremities : No abnormality was found
Localized state :
• Abdomen :
I : symmetrical, distention (-)
A : peristaltic (+) normal
P : pain (+) Mc Burney Point (+),
Rovsing Sign (-), Obturator (-),
Blumberg sign (-), psoas sign (-),
muscular rigidity (-)
P : tymphani, liver dullness (+)
• Digital Rectal Examination :
Perineum normal, tight anal sphincter
tone, smooth mucosa, pain (+) on 11-
12 o’clock, ampulla recti was filled
with feces.
Gloves : stool (+), blood (-) mucous (-)
 Laboratory Finding :
• Hb/Hct/Wbc/Plt : 14,6/43.40/5.61/260.000
• Neutrofil : 82.5
• Random Blood Sugar : 101
• Urinalysis : in normal limit
 Working Diagnosis :
Susp. Acute Appendicitis
 Management at ER:
• Nil per mouth
• Insertion of urinary catheter  came out initial urine 150cc,
UOP 60 cc/hr
• IVFD Crystalloid
• Inj. Antibiotic
• Inj. Analgesic

• Prepare for appendectomy

In Operating theater
• Patient in supine position with General Anasthesia ETT, aseptic and
antiseptic procedure was performed.
• Performed Gridiron incision, skin, subcutaneous, and fascia was
opened sharply and muscles was opened bluntly.
• Peritoneum were opened.
• Seen that omentum directed to right illiac fossa, adhesion was not
found and then omentum was released
• Identification of appendix, appendix was on retrocaecal, erectile and
erythema, sized 7 x 1 x 1 cm, perforation was not found.
• Appendicular vessels in mesoappendix were ligated.
• Appendectomy was perfomed with double ligation.
• Bleeding was controlled.
• Abdominal cavity was cleaned with wet gauze
• The surgical wound was closed layer by layer
• Operation was done
During Operation
Post Operation