Duty Report

Sunday, September 29th

2013

In Emergency Installation, we received 6 patients, consist of:

1. Excoriation wound : 2 pts WT+AG discharged
2. Laceration wound : 1 pt WT+ST+AB+AG discharged
3. Mild head injury GCS E4M6V5=15, Uncomplicated closed fracture
of proximal left radial neck (Mason type III), Laceration wound on
right zygoma region, Multiple excoriation wound (facial and left feet
region) : 1 pt Splint application+WT+AG refuse for further
treatment
4. Uncomplicated closed fracture of left humerus 1/3 middle comm,
Uncomplicated closed fracture of right glenoid (Ideberg type III),
Uncomplicated closed fracture of 2nd -8th lateral right ribs, Right
hemothorax after WSD application ec accident (6 days ago) 1 pt
Splint application + AGTHT
5. Acute Appendicitis, Hiperglycemia : 1 pt Laparascopy
appendectomy MRK 1st floor

CASE REPORT
A female 53 years old, consulted from internist department with
chief complain pain on the right lower abdomen.
H.O.I
2 days before admission, she felt pain on the umbilical area without
nausea or vomit. she had no fever. She went to GP, got some
medicine, but did not feel better.
1 day before admission the pain shifted to the right lower abdomen,
nausea (+), vomit (+) and fever (+). The pain become more intense
if she walked and cough. By her family she brought to Kariadi
General Hospital. There was no problem with defecation and
mixturation.
History of Past Illness :
Hipertension (-), DM (-)
Total Histerectomy caused by Ovarial cyst and Myoma (2003)

P.E :
General Condition : conscious
Vital sign : BP : 120/70 mmhg
PR : 86 x/mnt
RR: 20 x/mnt

t : 38,2C (R)

Head/neck : Conj.palp was not anemic

Sclera was not icteric
Chest :
Heart : I : ic was not seen
P : ic was palpable at 5th ics, 2 cm medially MCL
P : configuration w.n.l
A: pure heart sound, no murmur

Lung :

I : symetric right and left hemithorax on static

symetric right and left hemithorax on dynamic
P : tactile fremitus was equal on both side
P : sonor on all area
A : basic sound was vesicular, no additional sound
Abdomen : I : flat, bowel pattern/movement (-), scar (+) midline
below umbilical region
P : supel, tenderness on the right lower abdomen,
muscle rigidity (-), rebound tenderness (+),
rovsing sign (+).
P : timpanic, LD (+) N, SD (-), LD (+)
A: bowel sound (+) normal
Psoas sign (+)
Obturator sign (-)

Genitalia : female, w.n.l

Extremity :
Ekstremity
Sianosis
Cold acral
Capp. Refill
Motoric
Sensory

Supor
-/-

-/<2/<2
555/555
+/+

Infor
-/-/<2/<2
555/555
+/+

D.R.E :
adequate anal sphincter tone, smooth mucous, no mass/tumor,
ampula recti was not colaps, tenderness (+) on 9 10 o`clock area.
Glove : stool (+), mucous (-), blood (-)

Dx : Acute appendicitis

Laboratory study :
Hb
Ht
Leu
Plt
PPT
APTT
GDS

: 13,2 gr %
Ureum
: 23 mg/dl
: 42,9 %
Creatinin : 0,61 mg/dl
: 12.900 /mm3
Na/K/Cl : 142/4.1/105
: 168.000 /mm3
: 12.1 dtk
: 33,1 dtk
: 298 mg/dl

ECG : NSR

Urinalisa:
Color
: Yellowish clear
Protein
: 100 mg/dl
BJ
: 1,020
reduksi
: 500 mg/dl
pH
: 8,5
Urobilinogen : 0,2 mg/dl
Sil Hyalin : Bilirubin
:Sil granula kasar : Aseton
: 40 mg/dl Sil granula halus : Nitrit
: neg
Sil Epitel
:Epitel
: 2 5 LPK Sil eritrosit : Leukosit
: 0 1 LPB Sil leukosit : Erytrosit
:Bakteri
:+
Ca oxalat
:As.urat
:Triple fosfat
:Amorf
:-

Modified Alvarado Score

A : Appendicitis pain point
=2
L : Leucocytosis
=2
V : Vomitus
=1
A : Anorexia
=1
R : Rebound tenderness = 1
A : Abdominal migrated pain = 1
D : Degree of Celcius
=1
O : Cough pain
=1
Total
= 10

WDx : Acute appendicitis + Hiperglycemia

Management :
- Informed consent
- Inj. Insulin 10 UI
- Inf. Lactat Ringer 20 dpm
- Inj. Ceftriaxon 1 gr iv
- Pro appendectomy laparascopic consult senior onsite +
Digestive surgeon accepted

OPERATION REPORT
1. Operation was done under GA.
2. Performed catheter uretra no. 16 Fr
3. Desinfection operation area, narrowed with sterile clothes.
4. Performed transverse incision upper umbilical +10-12 mm,
deepen layer by layer until linea alba.
5. Clamp and lift the linea alba, peformed vertical incision about +
10 mm, control suture with PGA 2.0.
6. Inserted 10 mm trochart through abdominal cavity insuflated
10 mmHg CO2 with flow rate 5 lt/mnt inserted videoscope
into abdominal cavity.
7. Identification: omentum seems to point toward the right lower
and partially attached to the abdominal wall
8. Inserted 1st trochart 5 mm port on right quadrant (lateraly
Abdominal rectus muscle), then put 2nd trochart entered the
median linea at suprapubic region (avoid bladder), placed 5mm
port

8. Explored and identified appendix: appendix was at antecaecal site,

hyperemis, edematous, no perforation
9. Cut the mesoappendic with harmonic scalpel, then tied base of the
appendix with endoloop (Polydioxanone) PDS 0, and cut appendix
size 8 cm in length and 1,5 cm in diameter; fecalith (-). Inserted
plastic bag into abdominal cavity, placed the appendix into plastic
bag and take the appedix out from abdominal cavity send to
pathologic departement.
10. Washed the punctum appendix with povidone iodine
11. Removed port 5 mm with views directly over the videoscope (make
sure no bleeding from the abdominal wall of blood vessels)
12. Identified caecum, ileum, gynecological organs and surrounding
organ w.n.l
13. Removed port umbilicus, fascia sewn back.
14. Operation finished.

Diagnose post op :
Acute appendicitis antecaecal site
Hiperglycemia
post appendectomy laparascopic
MRK 1st floor