S/M/54 yo

76.84.53
 Chief Complaint: Pain on the whole abdomen
It has been suffered by the patient since 5 days before
admitted to H. Adam Malik Hospital. Initially, the patie
nt felt pain on epigastric regio and move to right lower
abdomen and then spread to the whole abdomen. Fev
er (+) 3 days ago, nausea (+), vomiting (+) 5 days ago, d
iarrhea (-). Micturition (+) normally, defecation (-) sinc
e 3 days ago. Flatulence (-). History of trauma or trad
itional massage (-), consumption traditional medi
cines and pain killer (-). Patient was referred
from district hospital.
 Present state
Awareness : Alert
BP : 140/80 mmHg
HR : 96 x / i
RR : 22 x / i
T : 37.50C
VAS :5
 Generalized State
Head and neck : no abnormality was found
Chest : no abnormality was found
Abdomen : in localized state
Genitalia : male, no abnormality was found
Extremities : no abnormality was found
 Localized state
Abdomen
I : symmetrical, distention (+), visible bowel contour (-), visible b
owel movement (-)
P : tenderness (+) on the whole abdomen, muscular rigidity (+)
P : liver dullness (+), hypertympanic
A : peristaltic (-)

Digital Rectal Examination :

Perineum normal, loose anal sphincter tone, smooth mucose,
pain o/t whole clockwise, ampulla was filled with feces.
Gloves : stool (+), blood (-) mucus (-)
Localized state
 Laboratory Findings
Hb/Hct/WBC/Plt : 11.5/32/19.380/185.000
KGD : 199
Na/K/Cl : 136/4.5/105
Ur/Cr : 98/1.20
Chest X-Ray
 Working Diagnosis
Diffuse Peritonitis d/t Susp. Appendicitis Perforation
 Management at ER
• Nil per mouth
• IVFD Crystalloid 30 cc/KgBW  2.100 cc
• Insertion of urinary catheter  came out clear yellowish urine
for about 100 cc, UOP 40cc/hour (120 cc/3 hours)
• Insertion of NGT  came out greenish liquid about 100 cc
• Inj. Antibiotic  ceftriaxone 1 gr/ 12H
• Inj. Analgetic  ketorolac 30 mg/ 8H

Prepare for:
Laparotomy Appendectomy
 At the operating theatre
• In supine position, under GA-ETT, aseptic and antiseptic procedure
• The midline incision was made, skin, subcutaneous, linea alba, peritoneum was opene
d then came out pus ± 200 cc and taken sample for culture at microbiology departme
nt
• Seen omentum direct to right fossa iliac
• Identification of caecum,found appendix at retrocaecal position , size 9cm x 1cm x 1cm
,necrotic with perforation on mid shaft appendix
• Appendix was separated from mesoappendix, a.apendicularis was ligated using materi
al silk 2/0 tappared and cut, then continue performed appendectomy with double ligat
ion using material silk 2/0 tappared and appendix sent to pathology anatomy laborator
y to be histopathology examined.
• Abdominal cavity was washed with normal saline until clean .
• Surgical wound closed layer by layer with leaving drainage at rectovesical pouch
• Operation was done.