APPENDICITIS ACUTE CASE REPORT 201

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CASE REPORT
Preceptor : Dr. dr. Bambang Arianto, Sp.B FINACS
A. PATIENT IDENTITY
Name
Age
Address
Job
Lats education
MRS
Registry number

: Mr. Haris Suhartono

: 33 Years Old
: Gebang Kidul No. 67
: Enterpreneur
: Senior High School
: 02th June 2016, 12.21 PM
: 588014

B. SUBJECTIVE
PRIMARY SURVEY
Airway :
Corpus alenium (-)
Maksilofacial trauma (-)
Additional breath sounds (-)
Gaps (-)
Breathing :

I : Normochest, symmetric, retraction (-), RR: 20x/minute

P: Movement of the chestwalls symmetric, crepitation (-),
deviated trachea (-),widened ICS (-)
P : sonor/ sonor
A : breath sound vesicular +/+, Ronkhi -/-, Wheezing -/-

Circulatiom : HR : 80x/mnt
Blood pressure : 110/70mmHg
Warm akral (+,+,+,+)
CRT < 2 second
Disability :
Exposure :

GCS : 456
Round pupil isokor 3mm/3mm
(-)

SECONDARY SURVEY
Main complaint :
Lower right abdominal pain
HISTORY OF PRESENT ILLNESS :
Lower right abdominal pain has experienced since 3 day ago,
Pain through to the back, pain is intermittent . pain is increase when
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APPENDICITIS ACUTE CASE REPORT 201

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the patient tilted to the right or to the left , if the breath , the patient
also feels pain in the lower right abdomen . Nausea ( + ) , vomiting ( - )
, urinated a little , but not pain , clear yellow color . BAB ( + ) 1 day
ago , diarrhea ( - ) . thermal ( - ) , flatus ( + ), no other complaints, eat

and drink like, defecate and urinate normally.

HISTORY OF PAST ILLNESS:
History of such illness is denied, history of any operation in abdomen

is denied.
SOCIAL HISTORY : ALLERGIES HISTORY : Denied
C. GENERAL STATUS :
General state : Good
Weight: 68 kg
Blood pressure :110/70 mmHg
HR
: 80 x/minute
RR
: 20x/ minute
Tax
: 36,5 oC
Head/Neck : A-/I-/C-/DThorak s
I

: Normochest, symmetric, retraction (-)

: Movement of the chestwalls symmetric, crepitation (-),

deviated trachea (-), widened intercostals space (-)

: sonor/ sonor

: breath sounds vesicular +/+, Ronkhi -/-, Wheezing -/-

: Ictus does not seem

: Ictus no palpable, thrill (-)

: heart border normal

: S1S2 single, Gallop (-), Murmur (-)

COR

Abdomen
I

: Flat simetris

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APPENDICITIS ACUTE CASE REPORT 201

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P

: Soepel , tenderness right lower quadrant (+), H/L/R no

palpable

: timpani around the abdominal region, shifting dullness (-)

: bowel sounds (+) normal

Ekstremitas

o Warm akral
+
+
o Oedema

+
+

o Cyanosis

o CRT < 2 dtk

D. LOCALIST STATUS
Regio Right lower quadrant of abdomen
o I : Mass (-), hiperemi (-)
o P : Mc Burney sign (+), Contra Mc Burney (-), Rebound Fenomena (-),
Rovhsing sign (+), obturator sign (+), Psoas sign (+)
o P : Tympani
o A : Bowel sounds (+) N
o R Flank : Flank pain -/Flank mass -/Tenderness -/Percussion pain -/o RT: TSA (+) N, Ampula not collapse, mass (-), pain (+) at 9-11 oclock
HS : feces (+), mucous (-), blood (-)
E. DIAGNOSIS
Appendicitis Acute
F. PLANNING DIAGNOSIS: - Thorax photo PA, BOF, LLD
- Complete laboratory analysis for pre operation: DL, UL, SGOT, SGPT,
BUN, SC, PPT, aPPT
G. PLANNING THERAPY
- Pro Appendectomy
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APPENDICITIS ACUTE CASE REPORT 201

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- Infusion RL 3500 cc/24 hours
- Fasting
- Antrain 3x1 amp
- Omeprazol 2x1 amp
H. PLANNING MONITORING
- General state
- Vital sign.
- Patient complaints.
- Urine output

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APPENDICITIS ACUTE CASE REPORT 201

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DAILY SOAP
Date
03/6/16

Subjective
No pain in
right
lower
quadrant
of
abdomen
this day of
fasting
pre-op
no other
complaint
s
urination:
normal

Objective
General
state:
enough
VS:
Blood pressure :
110/70mmHg
HR:92x/m
RR:22x/m
Tax:36,3C

Head/Neck:
A/I/C/D (-)

Thorax:
cor/pulmo:
normal

Abdomen:flat
, tenderness
(+) , H/L/R
no palpable,
tympani,
bowel sounds
(+) N

Ext: normal

Assesment

Planning

Appendiciti
s acute
(prosurgery
today)

Planning diagnosis:
Planning therapy:
Infusion RL
3500 cc/24
hours
Fasting
Planning monitoring
:
General state
Vital sign
Complaints
Urine output

Status lokalis:
Regio Right
lower
quadrant of
abdomen
L: mass (-),
hiperemi (-),
swelling (-)
P:
Tenderness
(+)

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04/6/16 Pain at the

incision
Flatus +

General state:
enough
Vital Sign:
Blood pressure :
110/80mmHg
HR:89x/m
RR 23x/m
Tax: 36,8 C
Head/Neck:
A/I/C/D Thorax:
Cor/pulmo:
normal

wound
(+), pain
(+) blood
(-) pus (-)

Abdomen:
flat, dressing +
soepel,
tenderness - - - - +-Tympani
Bowel sounds (+)
N

Appendiciti
s acute(post
appendecto
my 1st day)

Planning diagnosis:
Planning therapy:
Infus RL 3500/
24 hour.
Injection
Antrain 3x1/2
amp iv
Planning monitoring
:
General state
Vital sign
Complaints
Urination
Defecation
Appendectomy
wound

Extrimity: normal
Localys status :
Regio Right
lower
quadrant of
abdomen
L:
appendectom
y wound (+),
mass (-),
hyperemia (-)
swelling (-),
F: tenderness
(+)

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APPENDICITIS ACUTE CASE REPORT 201

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05/6/16 No Pain at
General state:
the incision enough
Vital Sign:
Blood pressure :
110/70mmHg
HR:88x/m
RR 24x/m
Tax: 36,2 C
Head/Neck:
A/I/C/D Thorax:
Cor/pulmo:
normal

Wound
(+), pain
(-) blood
(-) pus (-)

Abdomen:
flat, there
appendectomy
wound, soepel,
tenderness - - --+-Tympani
Bowel sounds (+)
N

Appendiciti
s acute(post
appendecto
my 2nd day)

Planning diagnosis:
Planning therapy:
Infus RL
1500cc/ 24 hour.
Injection
Antrain 3x1/2
amp iv
Planning monitoring
:
General state
Vital sign
Complaints
Urination
Defecation
Appendectomy
wound

Extrimity: normal
Localys status :
Regio Right
lower
quadrant of
abdomen
L:
appendectom
y wound (+),
mass (-),
hyperemia (-)
swelling (-),
F: tenderness
(+)

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APPENDICITIS ACUTE CASE REPORT 201

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06/6/16

No Pain at General state:

the incision enough
Vital Sign:
Blood pressure :
110/70mmHg
HR:88x/m
RR 24x/m
Tax: 36,2 C

Appendiciti
s acute(post
appendecto
my 3rd day)

KRS
Mef. Acid 3 x 500
mg
Ciprofloxacin 3 x
500mg
Control to surgery
department 3 day in
the future

Head/Neck:
A/I/C/D Thorax:
Cor/pulmo:
normal
Abdomen:
flat, there
appendectomy
wound, soepel,
tenderness - - --+-Tympani
Bowel sounds (+)
N
Extrimity: normal
Localys status :
Regio Right
lower
quadrant of
abdomen
L:
appendectom
y wound (+),
mass (-),
hyperemia (-)
swelling (-),
F: tenderness (+)

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