KS/M/ 28yo

Chief Complain : Pain on the whole abdomen

It has been suffered by the patient since 12 hours

before admitted to Adam Malik Hospital. It was felt
contineously. Initially it was felt in the right lower
abdominal about 1 days ago, then spread to the
whole abdomen like nowdays. History of fever (+)
since today, nausea (+), vomiting (+). Micturition (+)
normally, flatulent (+), Defecation (+) normally.
Present state :
Awareness: Alert
BP : 120/80 mmHg
HR : 94 bpm
RR : 20 times/min
T : 37,7 °C
VAS :6
Generalized State

Head : no abnormalities
Neck : no abnormalities
Chest : no abnormalities
Abdomen : in localized state
Extremity : no abnormalities
Genitalia : male, no abnormalities
Localized state

Abdomen: I : symmetryc, distension (-),

multiple skin lesion
P : pain (+) on the whole
abdomen,
muscular rigidity (+)
P : tymphani
A : peristaltic (-) decrease
Localized stat
Digital rectal Examination:
Perineum common, loose anal sphincter tone, slippery mucosa,
pain (+) on all direction, ampulla recti filled with stool, gloves :
stool (+), blood (-) mucous (-)
Laboratorium findings:

•Hb / Ht / L / Plt : 15.9/46/14.57/ 226

•Ur / Cr : 28/0.68
•Na / K / Cl : 137/3.4/105
•Random Glusoce Level : 133
CXR
Working Diagnose:
diffuse peritonitis d/t susp. Appendicitis
perforation + Susp. skin psoriasis
• Management in the ER:
– Nil per mouth
– Insertion NGT came out yellowish liquid 30 cc
– Insertion Foley catheter → UOP 60 cc/hour
– IVFD crystalloid
– Inj. Antibiotic
– Inj. Analgesic
– Prepare for laparotomy appendectomy
– Plan : Consult Dermatology & Venerology
Departement
In Operating theater
• Patient in supine position under ETT general anasthesia, aseptic
and antiseptic procedure.
• The midline incision was performed, cutis, subcutaneous, fascia,
peritoneum was opened came out pus about +100 cc, take for
culture examination.
• Seen omentum direct to the right fosa Illiaca, it preserved then
continued with identification of caecum, seen appedix with
antecaecal position, size 8 x 1.5 cm, hyperemic, it showed
perforation in shaft of appendix diameter 0,3cm.
• Mesoappendix separated from the appendix, appendectomy was
perfomed with double ligation, then bleeding control was
performed.
• The abdomen cavity was washed with normal saline until clean.
• The surgical wound was closed layer by layer with leaving drain at
the rectovesica pouch.
• Operation was done.
Thank you