COLIC ABDOMEN EC

APPENDICITIS
By:
Arya Maheswara Wardhana M, MD
Supervisor:
M. Diana Rahim, MD

INDONESIAN DOCTOR INTERNSHIP PROGRAM

GUNTUR HOSPITAL GARUT
2022
PATIENT IDENTITY

Nn. D/22 y.o./09683

June 11 2022/20.27
GP : Emil Eviliana, MD
 HISTORY TAKING
Patient come to emergency room of Guntur hospital with the complains of lower
right abdominal pain since 1 days. Pain felt sudden in lower right abdomen, does
not radiate, and felt continuously. Complains accompanied by nausea and hard to
fart since 2 days. Complains not accompanied by fever, vomitus. Urination
normal, hard to defecate.
Disease history (-)
History of drug use (-)
 PHYSICAL EXAMINATION
General Condition : moderately illness
Awareness : Compos mentis
GCS : 15
Blood pressure : 110/70 mmhg
Pulse Rate : 87 x/minute
Respiratory Rate : 20 x/minute
Temperature : 37,0 C
Oxygen Saturation : 98% free air
 PHYSICAL EXAMINATION

Head

Eyes : anemic conjungtiva -/-, icteric sclera -/-

Nose : nostring breathing (-)

Mouth : cyanosis (-), wet oral mucosa

Neck : lymph node enlargment (-)

Thorax : symmetrical chest movements

Cor : S1 S2 regular, gallop (-), murmur (-)
Pulmo : vesicular breath sounds , crackles -/-, wheezing -/-
 PHYSICAL EXAMINATION

Abdomen : flat, soepel, bowel sound (+) normal, tenderness (+) ar right inguinal, mc
burney sign (+), psoas sign (+), obturator sign (+), rovsign sign (-)
Liver : within normal limits
Spleen : within normal limits

Extremities :
warm, CRT <2 seconds, Edema (-)
 SUPPORTING EXAMINATION

The Result of Laboratory Examination (June 11 22)

 Blood routine
- Hb : 12,6 gr/dL
- Leukocyte : 15.400/mm3
- Trombocyte : 231.000/mm3
- Ht : 38,8
- Erythrocyte : 4,51 millions/mm3
-Diff. count : 1/1/0/77/16/5
 Immunology
Rapid antigen Covid-19 : Negative
 DIAGNOSE

Colic abdomen ec susp. Appendicitis

MANAGEMENT
 IVFD RL 20 dpm macro Advice dr.Tito, Sp.B
 Inj. Ranitidine 2x1 amp IV  Acc non-isolation ward
 Inj. Teranol 3x1 amp IV  Surgical operation plan
 Inj. Cefotaxime 2x1gr IV
 Pronalges 3x1 supp PO
 FOLLOW UP
June 12 2022 June 13 2022

Lower right abdominal pain (+), nausea (+)

Subjective Lower right abdominal pain (+), nausea (+)

CM CM
BP: 100/60 mmhg BP: 110/70 mmhg
RR : 20 x/m RR : 20 x/m
N : 82 x/m N : 91 x/m
Objective
T : 36,0 C T : 36,9 C
Sp02 : 98% free air Sp02 : 98% free air
Abdomen: Tenderness (+) ar right inguinal, mc Abdomen: Tenderness (+) ar right inguinal, mc burney (+),
burney (+), psoas (-), obturator (+), rovsing (-) psoas (-), obturator (+), rovsing (-)

Colic abdomen ec susp. app

Colic abdomen ec susp. app
 IVFD RL Loading 500cc, next 30 dpm
 IVFD RL Loading 500cc, next 30 dpm
 IVFD RL 20 dpm macro
 IVFD RL 20 dpm macro
Diagnose and  Inj. Ranitidine 2x1 amp IV
Planning  Inj. Ranitidine 2x1 amp IV
 Inj. Teranol 3x1 amp IV
 Inj. Teranol 3x1 amp IV
 Inj. Cefotaxime 2x1gr IV
 Inj. Cefotaxime 2x1gr IV
 Pronalges 3x1 supp PO
 Pronalges 3x1 supp PO
 Appendectomy surgery plan on Monday, June 13 2022
 OPERATION REPORT
Pre-Operation Diagnosis: Peritonitis ec. Appendicitis perforation
Post-Operation Diagnosis: Peritonitis ec. Appendicitis perforation
Operation: Laparoscopy + apendictomy
Anesthesi: General anesthesia
Anesthesia hours start: 15.30
Operation hours start: 15.40
Operation hours end: 16.30
Surgery:
-Supine patient position
-Perform aseptic and aseptic procedures
-surgical area incision
-found a perforated appendix with a diameter of 6-7cm
-performed laparoscopy and appendectomy
-suture the wound layer by layer
-cover the wound with sterile gauze
-operation completed
Post surgery instruction:
1. Observation of vital signs
2. Infusion RL:D5 1:1 20 drops per minute
3. Therapy: cepoperazone 2x1 IV; pronalges supp 3x1;
Dekketoprofen 2 amp drip 20 drops per minute; ranitidine
3x1 amp IV
4. Fasting until Bowel sound(+)