EMERGENCY CASE REPORTS

Tuesday, November 6 th 2018

SURGERY DEPARTMENT

EMERGENCY ROOM
Wahidin Sudirohusodo General Hospital
Makassar
EMERGENCY CASE REPORT
Tuesday, November 6 th 2018
Ambulation : - Patient
Hospitalized : 7 Patients
Observation : - Patient
Operated : 1 Patient
Death : - Patient
Total : 8 Patients

Wahidin Sudirohusodo General Hospital

Makassar
 Name : Mrs. M Age : 13 yo
RM : 862063 DPJP : dr. AW

Chief complain : Pain at whole abdomen

History taking : This condition had been apparent since 1 day before admitted to
the hospital and became severe. Initially he felt pain at epigastric
region then move and settled at right lower quadrant of abdomen
since 5 day ago. The pain is continuously and felt like stabbed.
There was history of fever, nausea and vomiting. Patient was
reffered from Syeikh Yusuf hospital.

Micturation normal

Defecation normal
General Status
Severe illness / normal nourish / conscious
Karnofsky 70%

Vital Sign
BP : 110/60 mmHg
HR : 90 x/min, adequate , regular,
RR : 22 x/min, symmetric, thoracoabdominal type.
T(Ax) : 38,1°C
Abdominal
Local Status
I : distended, follow breath motion, darm contour (-), darm steifung
(-),
A : Peristaltic (+) decrease
P : Tenderness (+) at whole abdomen, defans muscular (+) at whole
abdomen
P : Tapping pain at whole abdomen(+), tympanic (+)
Digital Rectal Examination
Sphincter ani was loose
Rectal mucosa smooth
Ampulla recti filled with feces
No palpable mass
Handschoen: blood (-), feces (+), slime (-)
 CLINICAL DIAGNOSIS
• Generalized peritonitis due to suspect
appendicitis perforation
 Laboratory findings :
• Hb : 12.4  SGOT : 23
• Hct : 37  SGPT : 13
• WBC : 19.600  Ureum : 22
• Neut : 82.7  Creatinin : 0.38
• Lymph : 10.2  GDS : 85
• Mono : 56.3  Na : 141
• Eo : 0.4  K : 3.9
• Baso : 0.4  Cl : 101
 PLT : 368.000
 APTT : 12.3
 PT : 21.7
 : Generalized peritonitis due to suspect
WORKING
DIAGNOSIS appendicitis perforation

MANAGEMENT : • IVFD
• Urine Catheter
• NGT
• Medicaments (broad spectrum
antibiotic)
• Plan for immediate Laparotomy
appendectomy
 Operation procedure
• Patient supine under general anesthesia
• Disinfection and drapping procedure on abdomen
• Perform midline incision 1 cm above umbilicus through 2 cm above
pubic symphysis, deep into peritoneum
• Open peritoneum, camae out pus about 50cc, and cultured pus
• Identify caecum, identify appendix, seen appendix antececal and
perforate on proximal appendix, and there was adhesion on
omentum with ileocaecal grade II and perform adhesiolisis
• Perform appendectomy continued with double ligation
• Bleeding control, washed abdominal cavity with saline until clean
• Put 1 drain on Douglas cavity
• Stitch operated wound layer by layer
• Operation is finished
Operation finding
POST op DIAGNOSIS : Generalized peritonitis due to appendicitis
perforation

Prognosis :
Dubia

Follow Up : - Vital sign

- Drain production
- Wound healing