CASE REPORT

Fryday, 22nd , 2016

Team on duty
dr. Nazir
(Jaga 1)
dr. Tommy Rivelino
(Jaga 2)
dr. Raja Raharja
(Jaga 3)
dr. Aswad Affandi
(Jaga 3)
dr. Arfan Asmadi
(Jaga 4)
dr. Ike Yoganita
(Jaga 5)
dr. Syahmardani
(Jaga 5)
dr. Jufrialdi
(Jaga 6)
dr. Arie Nasir
(Jaga 6)
Patient identity:
Name
: Muslimah
Age
: 7 years old
Sex
: Girl
Address
: Ds. Keude Meukek Kec. Meukek
Kab. Aceh Selatan
MR
: 1 08 79 31
Fathers phone
: 082165918589
Body Weight
: 17 kg
Admission time
: 20.00
Time Response
Date/Ti
me
patient
came to
ER

Examinati
on hour

April
22th
2016
20.12

20.15

Laboratory
Examinatio
n

Radiology
Examinatio
n

Sen
d

Resu
lt

Sen
d

Resu
lt

20.1
5

21.00

Time of
Diagnosti
cs

Date/
Time
patie
nt
out
from
ER

DPJP

21.00

16.00

Dr. Dian
Adi,Sp.
BA

Chief complaint:
Pain at the right lower abdomen region
Presenting history:
Patient was reffered fron Yulidin Away South Aceh District Hospital to Zainoel
Abidin emergency room with a chief complaint Pain at right lower abdomen region
abdomen for 1 weeks ago. Innitally, Patient fell pain at epigastric region and then

pain was spread at the right lower abdomen. History of medication from public health
(+). Then she was hospitalized for 4 days at distric hospital. History of fever (+),
Nausea and vomiting was present. There was no abnormality in urinate and
defecation. She was performed abdominal x ray from district hospital.
Physical examination:
V/S :
Consciousness
: Alert
Heart Rate
: 110 beats/ minute
RR
: 22 breaths/minute
T
: 37,0 C

L/S at the lower right abdominalregion:

I : Symmetrical,distention (+)
A: Bowel sound (+)
P : Pain (+) at Mc.Burney, Muscular rigidity (+) at the right lower abdomen.
P : Thympani (+), liver dullness (+)
Digital rectal examination :
Spinchter Ani : Tight
Ampula Recti : Empty
Mucosa Recti : Smooth
Pain
: Pain (+)
Glove
: Blood (-), Feces (+).
Abdominal X Ray
There was dilatation of bowel
There was fecalith at the right lower quadran
Assessment:
Susp Appendicitis perforasi
VAS : Moderate
Management:
Stop oral intake
Urinate catether
IVFD RL 1400 cc/ 24 hours
Inj.Cefriaxone 850 gr/ 12 hours
Inj. Metronidazole 125 mg/ 8 hours
Inj. Metamizole sodium 350 mg/8 hours
Laboratory examination
Laboratory result:

Hb
Ht
WBC
Platelet
CT
BT
Sodium
Potasium
Chloride
USG
Target sign (+)

: 11.9 gr/dl
: 37 %
: 12.300 /ul
: 549.000 /ul
: 7 minutes
: 2 minutes
: 143 mmol/L
: 4.5 mmol/L
: 104 mmol/L

Diagnose
Appendicular infiltrat
dd. Appendicular abscess
Consult to pediatric surgery division
Laparotomy exploration
Operative report
Peritoneum was opened there was mass appendicular infiltrat at the caecum
There was walling off at the caecum area and Identified adhesion.
Release of adhesion adhesiolisis
Identified of caecum fecalit
There was appendict at the retrocaecal, length 8 cm, with perforation at the body.
Performed appendectomy
Operation area rinse with gauze normal saline and performed
Operation wound closed by primary sutured
Post op diagnose:
Appendicular infiltrat (ICD 10 CM K36)
Follow up:
Date
S

April
24th
2016
POD II

Pain
(-)

Vital sign
Blood pressure :
110/80 mmHg
Pulse
:
90
beats/mnt
RR
:
20
breaths/mnt
T : 36,7 C
S/L
on
the
abdominal region :
I:
Simetric,
distention
(-), wound dry (+)
A: Bowel sound
(+)
P: Pain (-)
P: Tympani

Post
Laparotomy
Appendectomy
Appendicular
infiltrat
(ICD 10 CM K36)

IVFD RL 1800 cc/ 24

hours
Inj.Cefriaxone
850
mg/ 12 hours
Inj. Metronidazole 120
mg/ 8 hours
Inj.
Metamizole
sodium 350 g/8 hours
Wound care