Case Appendicitis Akut

7/21/2019 Case Appendicitis Akut

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Case Appendicitis akutMichael.D

FK UNTAR/406127056

Pembimbing:!."#han $%ca&.'(.)



Identitas pasien

Nama: Nn.*nah P%!na+an,iUm%!: 17,hnPenii-an ,e!a-hi!: 'MPAgama: &lamPe-e!aan: 'ale& -#&me,i-



Anamnesis

Kel%han U,ama : Ne!i (e!%, -anan ba+ah &ea- 1 mgg 'MR'

Ri+aa, Pena-i, 'e-a!ang : Ne!i (e!%, -anan ba+ah &ea- 1 mgg 'MR',e!%& mene!%& l#-a&i ne!i (e!,ama -alii!a&a-an i (e!%, -anan ba+ah (e!%, -i!i

ba+ah (e!%, -anan ba+ah ,e!a&a lebih ne!ibila be!ge!a-.Demam 3 i!a&a-an 12 ha!i&e,elah ne!i (e!%, -anan ba+ah . M%al 3 M%n,ah 3



ai ,e!a-hi! 8 &e,engah b%lan lal% i&e!,aiKe(%,ihan &e,ia( ma% men&,!%a&i-en,al ,ia-be!ba% ,ia- ga,al men&,!%a&i ,e!a,%! &elama 7ha!i8 9&#,e; &ei-i, ne!i (e!%, &aa, men&,!%a&i.Ri+aa, ma-an 9; 1ha!i

Ri+aa, ma-an : 9; &eha!i

Ri+aa, min%m : #& menga-% a!ang min%m

Ri+aa, )A) : !e-%en&i 1;/12 ha!i -#n&i&,en&i(aa, ,ia- aa leni! a,a% a!ah

Ri+aa, )AK : 1mgg lal% &em(a, ananganangannam%n hana 1; &aa #& %ga menga-% &e!ingmenahan -encing



Riwayat Penyakit dahulu

Ri+aa, a&ma 3 Ri+aa, #(e!a&i 3 Ri+aa, &a-i, lamb%ng 3



Status Generalis

Keaaan %m%m: Tam(a- &a-i, &eangKe&aa!an: <#m(#& men,i&Te-anan Da!ah: 100/70 mmgNai :=4;/ meni,RR: 20 ;/meni,

'%h%: 966#

<



Status Lokalis a/r Abdomen

Inspeksi : datar, lembut

Auskultasi : BU (+)

Palpasi : NT (+) di titik McBurney, DeenceMuscular (!), "#$sin% si%n (+), Blumber% si%n(+), Ps#as si%n (+), Massa (!)

Perkusi : Timpani

"T : Tidak dilakukan



Alvarado Score

The modiiedAlvarado score

Skor

>eala Pe!(inahan ne!i a!i

%l% ha,i -e -anan ba+ah

0

M%al ? m%n,ah 1

An#!e;ia 1

Tana Ne!i (e!%, -anan ba+ah 2

Ne!i le(a& 1

Demam ia,a& 975@< 1

Peme!i-&aan $ab $e%-#&i,#&i& 0

i,%ng eni& le%-# &hi,

,# ,he le,

0

T#,al 6

n,e!(!e,a&i ha&il 'anga, m%ng-in a(( a-%,



Alvarado Score

n,e!(!e,a&i M#iie Ala!a# 'c#!e

1 ? 4 'anga, m%ng-in b%-ana((enici,i& a-%,

5 7

'anga, m%ng-in a((enici,i& a-%,

=10 Pa&,i a((enici,i& a-%,



!ia"nosa #andin"

A((enici,i& A-%,Kehamilan *-,#(i- Te!gangg%Pelic nlamma,#! Di&ea&e



Pemeriksaan penun$an"

Hb, Ht, trombo, LeukoGDS, Elektrolit, UrinalisaTes KehamilanRontgen ThoraxUSG Abdomen



Pemeriksaan Penun$an"Pemeriksaan %asil &ilai normal Satuan

b 115B 12 16 g/l

, 96 96 46 C

$e%-# 00 4000 ? 10000 /%$

T!#mb# 9==000 150000 ?

450000

/%$

)leeing ,ime 2E90@ 16 Meni,

<l#,,ing ,ime 12E00@ 611 Meni,

'>T 2 097

'>PT 41B 040

U!e%m 76B 1050 Mg/$

<!ea,inin 001 0619 Mg/$

>D' =6 =0120 Mg/$



Pemeriksaan Penun$an"Pemeriksaan %asil &ilai normal Satuan

U!ine leng-a(

$e%-#&i, /(#&2 Nega,i

*!i,!#&i, /P' Nega,i

'eimen

*!i,!#&i, 12 01

'iline! Nega,i Nega,i

K!i&,al 3<a #-&ala, Nega,i

*(i,el ge(eng 95 02)a-,e!i Nega,i Nega,i

"am%! Nega,i Nega,i

Te& -ehamilan Nega,i Nega,i



Pemeriksaan Penun$an"

R# Th#!a; : )NU'> Ab#men :

U,e!%& %-%!an 7;4cm

Ane;a )N

<ai!an beba& in,!aab#men 3

Tia- aa -elainan gnec#l#gi& &eca!a

%l,!a&#n#g!ai&



!ia"nosa 'er$a

Appendicitis Akut



Penatalaksanaan

Pre !"erati# $%&'D RL

'olle( kateterPuasaR) A""endiktomi%nstruksi "ost o" $Puasa sam"ai *U +-%&'D RL ./ tts)menit0e#triaxone 1 x 1 gr +i2-Ranitidin . x 1 am" +i2-Ketorola3 . x 1 am" +i2-



Rencana (onitorin"

b&e!a&i T/N/R/' (#&, #(e!a&ib&e!a&i balance cai!an GFD H %!ine

#%,(%,



Pro"nosis

Ad 2itam $ bonam

Ad #un3tionam $ bonam

Ad sanationam $ bonam



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Case Appendicitis Akut