Case Report

Tuesday, Desember 29th 2015

Team on Duty
dr.Nizarli
(Jaga
dr. Aa Ahmad Dimyati
dr. Andri Mulia
dr. T. Ronasky
dr. Arfan Asmadi
(Jaga
dr. Rachmad M.
dr. Andrian
(Jaga
dr. Iskandar Islam (Jaga
dr. San Winata

1)
(Jaga
(Jaga
(Jaga
4)
(Jaga
5)
6)
(Jaga

2)
3)
3)
4)

6)

Patient identity
Name
: M. Arief Andisha
Age
: 11 years old
Sex
: Boy
Address
: Ds. Balee Panah, Kec. Juli Kab. Bireuen
Fathers Phone
: 081269829494
MR
: 1 07 58 88
Body Weight : 30 kg
Admission time
: 19.00 WIB
Time Response
Date/h Examinatio Laboratory Radiology
Hour of Date/hou
our
n hour
Examination Examination Diagnosti r patient
patient
cs
out from
Sen Result Send Result
came
ER
d
to ER
Decemb
er 29th
2015
19.00

19.00

19.30 20.30

20.30

DPJP

December
Dr.
29th 2015 Muntadhar,
Sp.B.Sp.BA

Chief complaint
Pain at the whole abdominal region
Patient illnes history
The patient consult from pediatric department. referred from Bireuen district
hospital to Zainoel Abidin Emergency Room with a chief complaint pain at the
whole abdominal region. Initially, pain felt at the right lower abdominal region
for 1 month, patient was hospitalize for 1 week at private hospital in Bireuen.
2 days ago the patient felt pain at the whole abdominal region and getting

worst, and than he referred to RSUDZA, History of nausea and vomit (+),
history of fever (+).
Physical examination
Vital sign :

Blood pressure
: 110/90 mmHg

Pulse
: 110 beats/minute

Respiratory rates : 24 breaths/minute

Temperature
: 37 oC
L/S at the abdominal region :
I : Symmetrical, distension (+)
A : Bowel sound (+) decrease
P : Pain and muscular rigidity (+) at the whole abdomen
P : Liver dullness (+), Tympani
Digital Rectal examination :
Tonus Spinchter ani: tight
Ampula recti
: Faeces (+)
Recti Mucous
: Smooth
Pain
: (+)
Glove
: Blood (-), faeces (+).
VAS : Moderate
Assessments :
1. General peritonitis due to susp. perforation of the appendicitis
2. Mild Moderate dehydration
3. Sepsis
Management
Stop oral intake
NGT clear
Urinary Catheter
IVFD RL 600 cc/ hour
(Rehidration 30 x 20 cc = 600 cc/ hour)
Maintanace RL = 1600 cc/24 hours
Ceftriaxone inj 1 g
Metronidazole 250 mg drip
Metamizole Sodium Inj 600 m g
Laboratory examination

Time

Urine (CC)

20.00

20

21.00

25

22.00

25

23.00

35

24.00

35

Laboratory result
Hb
:
White blood count :
Platelet
Ht
:
CT / BT
Glucose ad random
Sodium
Potassium
:
Chloride
:

11.8 gr/dl
20.200 /ul
: 432.000 /ul
35 %
: 7 / 2
: 132 mg/dl
: 139 mmol/L
3.8 mmol/L
105 mmol/L

Diagnosed
1. General peritonitis due to susp. perforation of the appendicitis
2. Mild Moderate dehydration
3. Sepsis
Consult to pediatric surgery division
Laparotomy explorasi + Appendectomy emergency
Operative report :
Performed midline abdominal incision
When peritonium was open, there was serous purulent fluid 50 cc
There was adhesion perfomed adhesiolis
Direct exploration to caecum, Identified appendix, retro caecal, erectil,
oedem, length 5 cm with perforation at apex of appendix
Appendix was release from messoapendix and performed appendectomy and
duble ligasi suture
Cavum abdomen rinse with normal saline until clean
Wound close with primer suture
Post operative diagnose
1. General peritonitis due to perforation of the appendicitis (ICD 10 CM C18.0)
2. Mild Moderate dehydration (ICD 10 CM E86.0)
3. Sepsis (ICD 10 CM A41.9)

Follow up :

Date
Januari
2nd
2016
POD 4

S
Pain
(-)

O
Vital Sign :
BP : 110/70 mmHg
RR : 22 breaths/mnt
Pulse : 84 beats/mnt
T: 36,8C
L/S at the abdominal
region :
I : wound operation (+)
dry
A: Bowel sound (+)
P: Pain (-)
P: Liver dullness (+)

Post laparotomy
exploration +
appendectomy
emergency
1. General
peritonitis due to
perforation of the
appendicitis (ICD
10 CM C18.0)
2. Mild Moderate
dehydration (ICD
10 CM E86.0)
3. Sepsis (ICD 10
CM A41.9)

Out of clinic