Patient Identity

Name : Ridho Ramadhan

Age : 19 years old
Sex : Male
Address : Meunasah Blang,
Peudada, Bireuen
MR : 110 21 34
Phone : 085260308163
Admission time : 06.30
 Time Response
Date Exami Laboratory Radiology Hour Date/h DPJP
/hou nation Examination Examination of our
r hour Send Resul Send Resul Diag patien
pati t t nosti t out
ent cs from
cam ER
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ER

23/9/ 06.40 06.50 08.45 09.30 10.15 09.45 23 Dr.

2016 septem Musli
06.3 ber m
0 2016 SpB-
KBD
Chief Complaint:
Pain at the whole abdominal region

Patient illness history

The patient came to Zainoel Abidin
hospital emergency room with a chief
complaint pain at the whole abdominal
region for 2 days. Initially the pain felt at
the right lower abdomen then spread to to
epigastric region and settle. History of
nausea and vomiting (+). History of fever
(+)
Physical examination
Vital sign :
Blood pressure : 105/80 mmHg
Heart Rate : 96 Beats/min
Respirator rate : 22 Breaths/Miniute
Temp : 38,2 oC

L/S at the abdominal region :

I : Simetris
A : Bowel Sound (+) decrease
P : Pain (+), Muscular rigidity (+)
P : Tympani, liver dullness (+)
Digital rectal examination
Sphincter ani : Tight
Ampulla recti : Pain
Mucosa : Faeces
At glove : faeces (+) blood (-),
mucous (-)
Assessment :
General peritonitis due to suspect
appendicitis perforation
 Vas : 6
Management
Stop oral intake
NGT clear
Urinary Catheter clear (initial + 70
cc)
Ceftriaxone 1 gr
Metronidazole 500 mg
Ketorolac inj 30 mg
Laboratory examination
Radiology examination
Laboratory result
Hb : 13,8 gr/dl
WBC : 28.200/ul
Platelet : 24.000/ul
CT/BT : 7/3
HT : 38 %
Diagnose
General peritonitis due to suspect
appendicitis perforation

Consult to digestive surgery

division :
Laparotomy appendectomy
emergency
Operative Report :
Performed infraumbilical incision layer by
layer until peritoneum.
Peritoneum was open came out pus abut
50 cc
Found adhesion caecum and colon
performed adhesiolisis
Identified appendix retrocaecal, lenght
8 cm, erectil, perforated at corpus
Performed appendectomy
Abdominal cavity was rinsed
Left 1 tube drain
Post operative diagnose:
General peritonitis due to
appendicitis perforation (ICD 10 CM
K63.2)
Intestinal adhesion (ICD 10 CM
K66.0)
Follow up
Dat S O A P
e
26/9/ Pain Vital sign : Post IVFD RL 20
2016 (+) BP : 110/60 mmHg Laparotomy drip/minute
POD decre HR : 88 beats/minute exploration Ceftriaxone 1
3 ase RR : 22 beats/minute appendectom gr/12 hour
Temp : 37,2 oC y+ Metronidazole
Adhesiolisis 500 mg drip/8
L/S at the abdominal region : due to hour
I : distension (-), wound covered 1.General Paracetamol drip
by gauze peritonitis 1 gr/8 hour
Drain : cc due to
A : bowel sound (+) appendicitis
P : pain (+) decrease, muscular perforation
rigidity (-) (ICD 10 CM Wound care
P : Tympani, liver dullness (+) K63.2) Stop oral intake
2.Intestinal Monitor for
Flatulance : (+) adhesion hemodynamic
Defecation : (-) (ICD 10 CM and urine output
Urine output : + 40 cc/hour K66.0)