Identity

Patogai Z Ahmad,Male, 8 y.o

RM : 00788625
Admission to hospital : 25-05-23, 12.55 WITA

Main Complaint :
Pain on right lower abdomen
 Anamnesis
Patient come with pain right lower abdomen 2 days
before admission to hospital. At the beginning, 5
days ago patient feels has nausea and pain at the
epigastrium site. After that, the pain migrate from
the epigastrium to right lateral quadrant. 1 days
before admission to hospital, patient pain
persistent at abdomen right lower quadrant.
Patient has taken to Hospital Siloam and then
transport to Prof. Kandou Hospital.
 Physical Examination
BP : 100/70 mmHg HR : 87times/m
RR : 20times/m T : 36,2 ̊C
VAS : 3

Head : within normal limit

Neck : within normal limit
Thorax : within normal limit
 Physical Examination
Abdomen :
Ins : Tense, Darm Countur (-), Darm Steifung (-)
Aus : Bowel Sound (+) decrease
Pal : Tendernes (+) right lower quadrant , Muscular
Defens (-), McBurney Sign (+), Blumberg Sign (+), Rovsing
Sign (+), Psoas Sign(+), obturator sign (-)
Per : Tymphani (+)

RT : TSA tight, ampullae collapse (-), smooth, mucosa,

HS : feces (-), blood (-), mucous (-)

Extremitas superior et inferior : within normal limit

Physical Examination
Working Diagnose
Acute Appendicitis
(ICD X: K35.0)
 Planning
Care Plan : Examination Support :
•Overcome pain •Count Blood Cell
•Overcome infection •Chest Xray
Pharmacology Therapy :
•IVFD NaCl 0,9%
•Analgetic
•Antibiotic
•Pro Appendectomy
Laboratorium
Thorax X-Ray
 ALVARADO SCORE

Point
Migration of pain 1
Anorexia 1
Nausea/vomiting 1
Tenderness RLQ 2
Rebound pain 1
Elevation temperature 0
Leukositosis 2
Shift of white blood cell 0
count to the left
TOTAL 8
 Diagnose
Acute Appendisitis
(ICD X: K35.80)
• Consult
Dr. dr. Harsali F. Lampus, SpBA(K)
Advice : Appendectomy cito
 Operation Report
• Patients sleep on their back on the operating table
with narcotics
• A and antiseptic operating field.
• Incision at MC Burney point
• Deepened incision layer by layer until the
peritoneum
• The peritoneum was opened and omentum found
at right lower quadran
 Operation Report
• Next identification, appendix was found at
retrosecal size 7 x 2 cm, hyperemic (+).
• Perform Appendectomy retrograde, procedure
with double ligation on the punctum of the
appendix.
• Operating wound closure layer by layer
• Operation finished
Intra Operating Picture
Intra Operating Picture
 Post Op Diagnose
Acute Appendicitis
(ICD X: K35.0)

Procedur:
Laparatomy Appendictomy (ICD IX:54.11)
Adhesiolisis (ICD IX: 54.4)