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Surgery Case


Created by :
Elmer Basila 1215107

Friska MB 0915175

Stella Vaniadewi 1215025

Regina Putri 1215041

Kisyana FK 1115196

dr. Eduard P. Simamora, Sp.B, Sp.BA

I. Patient’s Identity
Patient’s name : R. J. P
Gender : Male
Age : 11 years
Nationality : Indonesian
Address : Bandung
Sent from : Emergency Room (October 9th, 2017)
Entry diagnosis : Acute Appendicitis
Examination date : October 9th, 2017

II. Anamnesis
Heteroanamnesis from his mother
Chief Complaint: Right Lower Quadrant abdominal pain
Client was administered to Immanuel Hospital ER by his parents because client complaining
about abdominal pain especially in Right Lower Quadrant area since yesterday, the pain is
persistent and unbearable that client can barely slept at night, client felt nauseous and migrating
pain from epigastric area about 12 hours before Right Lower Quadrant pain. Client hasn’t felt
any fever, vomiting, client having appetite problem in past 2-3 days
Client was born at 38 weeks of gestational age at hospital, with birth weight 287 kg and birth
height 53 cm. client has complete immunization.
Physical Examination (October 9th, 2017)
• General Appearance : good
• Consciousness : compos mentis
• Weight : 36 kg
• Vital Sign:
• Pulse : 89x/min
• Respiration : 18x/min
• Temperature : 36,3⁰C
• Skin : anemic (-), cyanotic (-), icteric (-)
• Hair : black, heavy, not easily revoked
• Head : normal
• Eye : conjunctivae not anemic, sclerae not icteric, palpebrae not
• Ear, Nose, Throat : nostril breathing -/-, mucus -/-, blood -/-
• Mouth : lip not cyanotic, wet mucosa, T1 / T1, pharynx not hyperemia
• Neck : no lymph node enlargement, trachea on central position.
• Chest : symmetric shape and movement on both side
• Heart : normal heart sound, regular
• Lungs : VBS +/+, ronchi -/-, wheezing -/- , slyme -/-
• Abdomen : bowel sound (+) >>, defance muscular (+), mc burney tenderness
• Genital : scrotum : testis -/-
• Anorectal : no examination procedure done
• Extremities : warm, CRT < 2”

III. Resume
Client has Right Lower Quadrant abdominal since 1 day ago, persistent and unbearable. Client
feeling nauseous, and the pain was migrating from epigastric area to Right Lower Quadrant, and
decreased in appetite .Client has no fever. no complains to urinating and defecation.

The patient had normal vital sign.

Medication : appendectomy

IV. Laboratory Findings

Normal value 9 October 2017

Hb 11.8-15.0 14.1
Ht 35-47 39%
Leucocytes 4000-13500 13.740/mm3
Thrombocytes 150.000-450.000 236.000/mm3
Erythrocytes 3.8-5.2 4.5M/mm3`
MCV 77-95 86 fL
MCH 25-33 31pg/mL
MCHC 32-36 36g/dL

• Differential count:
Basophil :0.9
Eosinophil :1.1
Staff Neutrophil :0 (low)
Segemented Neutrophil :78.8 (High)
Lymphocytes :15.2 (High)
Monocytes :4
• Urinalysis
Within Normal Limits

V. Suggested Further Examination

Whole Abdomen USG
Chest X-ray
Abdomen X-ray

VI. Examination Finding

USG 9/10/2017
a. Liver: normal Shape and Size, flat surface, sharp edges. Homogenous parenchymal
texture, normal echogenicity, normal vasculature, normal bile duct
b. Gall Bladder: normal Shape and Size, flat not thickened wall, no significant
findings in intraluminal, normal peri gall bladder
c. Common Bile Duct: width within normal limits, no significant findings in
d. Pancreas: Shape and Size, flat surface, sharp edges. Homogenous parenchymal
texture, normal echogenicity, normal major pancreatic duct
e. Spleen: Shape and Size, flat surface, sharp edges. Homogenous parenchymal
texture, normal echogenicity, normal splenic vein
f. Intraperitoneal: Appendix hard to measure due to intraabdominal gases
g. Conclusion
i. Liver: within normal limits
ii. Gall Bladder: within normal limits
iii. Common Bile Duct: within normal limits
iv. Pancreas: within normal limits
v. Spleen: within normal limits
vi. Appendix: hard to measure due to intraabdominal gases
Chest X-ray 9/10/2017:
h. Central trachea, Normal Aorta, normal heart size, normal sinuses, normal
i. Lungs: Normal left & right Hilus, no significant soft patches within lungs
j. Normal clavicle and chest wall soft tissue
k. Conclusion: No active lung TB neither pneumonia, heart within normal limits
Abdomen X-Ray 9/10/2017
l. Normal Pre-peritoneal fat, normal psoas line, normal renal contour, normal sceletal,
no extraluminal free air
m. No opaque nodules, normal air distribution in colon, attached catheter in right lower
center quadrant
n. Conclusion: no signs of Pneumoperitouneum, urolithiasis, normal sceletal

VII. Diagnosis & Management

Pre-operation Diagnosis : Local peritonitis due to impending gangrene
Surgical treatment : Laparotomy Appendectomy
Post-operation Diagnosis : Acute appendicitis
VIII. Prognosis
Quo ad vitam : ad bonam
Quo ad functionam : ad bonam
Quo ad sanationam : ad bonam