A/M/25yo

9
Chief Complaint : Pain on the right lower abdomen
It has been suffered by the patient since 7 days before admitted to
Adam Malik Hospital. Initially patient had fever (+) intermitenly
followed by nausa (+) and vomiting (+) 3 times a day. However, pain
on the epigastric area was not significantly showed. Lately, he
complaint about lump on the right lower abdomen (+). History of
bloody defecation (-), feces like goat stool (-), diarrhea (-). History of
lost body weight (-). History of trauma (-). Micturition (+) normal.
Patient can’t defecate since 4 days ago. Patient was reffered from
distric hospital.
History of past illness: -
History of medication: -
Present state :
Awareness : Alert
BP : 110/70 mmHg
HR : 104 x / i
RR : 22 x / i
T : 38.5 °C
VAS :4
Generalized State
Head and neck : no abnormalities
Chest : no abnormalities
Abdomen : in localized state
Genitalia : male, no abnormalities
Extremity : no abnormalities
Localized state :
Abdomen :
•I : symmetrical, distention (-)
•P : Tenderness (+) at McBurney point,
palpable mass o/t (R) lower abdomen,
5x2 cm, firm consistention, smooth
surface, fluctuation (+), pain (+), muscular
rigidity (-)
•P : liver dullnes (+), tympani
•A : Peristaltic (+) normal, metalic sound
(-)
Digital Rectal Examination :
Perineum normal, loose anal sphincter tone, smooth
mucosa, tenderness (+) on 10-12 clockwise, rectum was
filled by feces.
Gloves : stool (+), blood (-) mucous (-)
Chest X Ray
Laboratory Findings:
Hb/Hct/Wbc/Plt : 11.60/7.43/13.05/264
Ur/Cr : 98/ 2.98
Na/K/Cl : 125/3.6/98
Random Blood Sugar : 407
Working Diagnosis :
Susp. Appendicial Abscess
Management at ER :
•Fasting
•IVFD Ringer Lactate 30 gtt/i
•Insertion NGT  came out about 50cc yellowish fluid
•Insertion urine catheter  initial 80cc, UOP 70cc/hour, clear
yellow urine
•Inj. Ceftriaxone 1 gr / 12 hours
•Inj. Ketorolac 30mg / 8 hours
•Plan:
– Laparotomy abscess drainage
In Operation Theatre
•Patient in supine position with spinal anasthesia, aseptic and antiseptic
procedure was performed.
•The grid iron incision was made, cutis, subcutaneous, fascia was
opned,muscle was split, peritoneum was opened.
•Identification of caecum, there was appendix was in retrocaecal position
with size 7 x 1 x 1 cm hyperemic erectile
•Appendix and mesoappendix were separated, appendiculary vessel was
ligated.
•Appendectomy was perfomed with double ligation, it send to pathological
anatomy department for histopathological examination.
•The abdominal cavity was washed with moist gauze until clean.
•The wound was closed layer by layer.
•Operation was finished