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    Arya Maheswara - Appendicitis

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    dianarahimm

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    Arya Maheswara - Appendicitis

    Uploaded by

    dianarahimm
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    13 views11 pages

    Arya Maheswara - Appendicitis

    Uploaded by

    dianarahimm

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 11

    COLIC ABDOMEN EC

    APPENDICITIS
    By:
    Arya Maheswara Wardhana M, MD
    Supervisor:
    M. Diana Rahim, MD

    INDONESIAN DOCTOR INTERNSHIP PROGRAM


    GUNTUR HOSPITAL GARUT
    2022
    PATIENT IDENTITY

    Nn. D/22 y.o./09683


    June 11 2022/20.27
    GP : Emil Eviliana, MD
    HISTORY TAKING
    Patient come to emergency room of Guntur hospital with the complains of lower
    right abdominal pain since 1 days. Pain felt sudden in lower right abdomen, does
    not radiate, and felt continuously. Complains accompanied by nausea and hard to
    fart since 2 days. Complains not accompanied by fever, vomitus. Urination
    normal, hard to defecate.
    Disease history (-)
    History of drug use (-)
    PHYSICAL EXAMINATION
    General Condition : moderately illness
    Awareness : Compos mentis
    GCS : 15
    Blood pressure : 110/70 mmhg
    Pulse Rate : 87 x/minute
    Respiratory Rate : 20 x/minute
    Temperature : 37,0 C
    Oxygen Saturation : 98% free air
    PHYSICAL EXAMINATION

    Head

    Eyes : anemic conjungtiva -/-, icteric sclera -/-

    Nose : nostring breathing (-)

    Mouth : cyanosis (-), wet oral mucosa

    Neck : lymph node enlargment (-)

    Thorax : symmetrical chest movements


    Cor : S1 S2 regular, gallop (-), murmur (-)
    Pulmo : vesicular breath sounds , crackles -/-, wheezing -/-
    PHYSICAL EXAMINATION

    Abdomen : flat, soepel, bowel sound (+) normal, tenderness (+) ar right inguinal, mc
    burney sign (+), psoas sign (+), obturator sign (+), rovsign sign (-)
    Liver : within normal limits
    Spleen : within normal limits

    Extremities :
    warm, CRT <2 seconds, Edema (-)
    SUPPORTING EXAMINATION

    The Result of Laboratory Examination (June 11 22)


     Blood routine
    - Hb : 12,6 gr/dL
    - Leukocyte : 15.400/mm3
    - Trombocyte : 231.000/mm3
    - Ht : 38,8
    - Erythrocyte : 4,51 millions/mm3
    -Diff. count : 1/1/0/77/16/5
     Immunology
    Rapid antigen Covid-19 : Negative
    DIAGNOSE

    Colic abdomen ec susp. Appendicitis

    MANAGEMENT
     IVFD RL 20 dpm macro Advice dr.Tito, Sp.B
     Inj. Ranitidine 2x1 amp IV  Acc non-isolation ward
     Inj. Teranol 3x1 amp IV  Surgical operation plan
     Inj. Cefotaxime 2x1gr IV
     Pronalges 3x1 supp PO
    FOLLOW UP
    June 12 2022 June 13 2022

    Lower right abdominal pain (+), nausea (+)


    Subjective Lower right abdominal pain (+), nausea (+)

    CM CM
    BP: 100/60 mmhg BP: 110/70 mmhg
    RR : 20 x/m RR : 20 x/m
    N : 82 x/m N : 91 x/m
    Objective
    T : 36,0 C T : 36,9 C
    Sp02 : 98% free air Sp02 : 98% free air
    Abdomen: Tenderness (+) ar right inguinal, mc Abdomen: Tenderness (+) ar right inguinal, mc burney (+),
    burney (+), psoas (-), obturator (+), rovsing (-) psoas (-), obturator (+), rovsing (-)

    Colic abdomen ec susp. app


    Colic abdomen ec susp. app
     IVFD RL Loading 500cc, next 30 dpm
     IVFD RL Loading 500cc, next 30 dpm
     IVFD RL 20 dpm macro
     IVFD RL 20 dpm macro
    Diagnose and  Inj. Ranitidine 2x1 amp IV
    Planning  Inj. Ranitidine 2x1 amp IV
     Inj. Teranol 3x1 amp IV
     Inj. Teranol 3x1 amp IV
     Inj. Cefotaxime 2x1gr IV
     Inj. Cefotaxime 2x1gr IV
     Pronalges 3x1 supp PO
     Pronalges 3x1 supp PO
     Appendectomy surgery plan on Monday, June 13 2022
    OPERATION REPORT
    Pre-Operation Diagnosis: Peritonitis ec. Appendicitis perforation
    Post-Operation Diagnosis: Peritonitis ec. Appendicitis perforation
    Operation: Laparoscopy + apendictomy
    Anesthesi: General anesthesia
    Anesthesia hours start: 15.30
    Operation hours start: 15.40
    Operation hours end: 16.30
    Surgery: Post surgery instruction:
    -Supine patient position 1. Observation of vital signs
    -Perform aseptic and aseptic procedures 2. Infusion RL:D5 1:1 20 drops per minute
    -surgical area incision 3. Therapy: cepoperazone 2x1 IV; pronalges supp 3x1;
    Dekketoprofen 2 amp drip 20 drops per minute; ranitidine
    -found a perforated appendix with a diameter of 6-7cm 3x1 amp IV
    -performed laparoscopy and appendectomy 4. Fasting until Bowel sound(+)
    -suture the wound layer by layer
    -cover the wound with sterile gauze
    -operation completed

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