EMERGENCY CASE REPORTS

Thursday, September 19 th, 2013

SURGERY DEPARTMENT

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
Thursday, September 19 th, 2013

Ambulation : - Patients
Hospitalized
: 4 patients

Observation : - Patient
Operated : 1 Patients
Death : Patient

Total : 4 patients
 No. 1
Name : Mr. S Sex : Male
Age : 25 years old No. Reg : 628902

Chief complaint : Right lower abdominal pain

History taking : The pain had been apparent for 1 day. The pain started in
the central abdomen and has now become constant and
has shifted to the right lower abdomen. the patient has
vomited twice today. There were event of fever for 1 day.

Defecation : Normally
Micturation : Normally
 Physical Examination

General Conditions:
Moderate illness/well nourish/composmentis

Vital sign:
BP : 110/70 mmHg
PR : 80x/mnt, regular, adequate.
RR : 20x/mnt.
T(Ax) : 38,3 C
PHYSICAL EXAMINATION
Abdomen
I : Flat. Follow breath motion, no bowel contour, no bowel motion. No
tumor mass

A : Bowel sound normally

P : Localized tenderness (-). Defans muscular (-). Mc Burney pain (+).

Rovsing sign (-), Blumberg sign (-)
P : Tympani, tapping pain (+)
 Digital Rectal Examination

Sphincter ani was tight,

Mucous was smooth,
Ampula was empty

Gloves : Faeces (-), blood (-), slime (-)

Laboratory Result
WBC : 17,48 x 103 /L

RBC : 5,5 x 106/L

HGB : 16,8 g/dL

HCT : 45,5 %

PLT : 197 x 103/L

CT / BT : 700/300

Blood Sugar : 96 mg/dl

Ureum : 17 mg/dl

Creatinin : 0,8 mg/dl

SGOT/SGPT : 20/14 u/l

 Kalesaran Score Labeda Score
Mual +7 +4
Muntah +11 +2
Demam +7 +7
Nyeri Batuk +15 +4
Nyeri Ketok +5 +10
Defans lokal -13 -11
Leukositosis +15 +6
Gender +13
TOTAL +47 +35
Interpretasi Kalesaran score Labeda Score
Operated > 19 > - 11
Observation - 15 s.d 19 -57 s.d -11
Not Appendicitis < -15 < -57
WORKING DIAGNOSIS : Acute appendicitis

MANAGEMENT : IVFD
Medicaments
Consult to Senior Digestive Surgeon
advice : immediate appendectomy
 OPERATION PROCEDURE
Patient lied in supine position with GA
Disinfection and draping procedure
Performed grid iron incision, deepen until peritoneum
Performed exploration, seen appendix phlegmonosa
at retro caecal
Performed retrograde appendectomy continue with
purse string
Bleeding control
Close the wound layer by layer
Done
POST OP DIAGNOSIS : Peritonitis generalisata ec. Appendicitis perforation

PROGNOSIS Good
FOLLOW UP Vital Sign
Acute abdomen