Thursday, March 1, 2018

Child F, 9 years old

Alansan Julio Sutanto

Leader Doctors: 1. dr. Iwan Irawan Karman, Sp.B(K)-KL, FICS

2. dr. Susilawati, Sp.A
 Identity
Name : Child F
Age : 9 years old
Address : Penjaringan
Occupation : Student
Admission : March 1, 2018 (15:00)
Examination : March 1, 2018 (15:00)
 History Taking
Chief Complaint:

• Pain on the right stomach

 History of Present Illness
• Patient came to the ER with persistent pain on the right
stomach 24 hours prior to hospital admission

• The pain was sudden, sharp, and felt like squeezing the
stomach (VAS 7-8)

• The patient lost his appetite because he was feeling

nauseous, he could only eat few pinches of bread, and he
vomited one time (liquid substance) before hospital
admission
 History of Present Illness
• Patient’s mother said there was fever but she didn’t
measure it with thermometer

• Earlier, patient went to a local clinic and was given

medicines, but the pain was not relieved. Then, the
patient was referred to Atma Jaya Hospital
 History of Past Illness
• Systemic disease : ( - )

• Medication :(-)

• Surgery :(-)

• Allergy :(-)

• Trauma :(-)
 Physical Examination
• Consciousness: compos mentis (GCS=15)

• Vital signs:
• Blood pressure : 110/70 mmHg
• Heart rate : 88x/minute
• RR : 22x/minute
• Temperature : 37 C
 Physical Examination
• Head: normocephaly, deformity ( - )
• Face: symmetry, paresis ( - )
• Eyes: round pupil, 3mm/3mm,
direct light reflex +/+, indirect light reflex +/+,
anemic conjunctiva -/-, icteric sclera -/-
• Nose: deviation ( - ), discharge ( - )
• Ear: deformity ( - )
 Physical Examination
• Oral cavity: dry lips
• Neck: lymph node enlargement ( - )
• Pulmonary:
• Inspection: hematoma ( - ), symmetrical breathing
• Palpation: symmetrical breathing movement & tactile
fremitus
• Percussion: sonor +/+
• Auscultation: vesicular +/+, ronchi -/-, wheezing -/-
 Physical Examination
• Cardiac:
• Inspection: ictus cordis not visible
• Palpation: ictus cordis not palpable
• Percussion: no signs of cardiomegaly
• Auscultation: regular heart sound, murmur ( - )
 Physical Examination
• Abdomen
• Inspection: appear flat, hematoma ( - )
• Auscultation: bowel movement (+) 3x/minute on RLQ
• Palpation: tenderness ( + ) on RLQ, Blumberg sign
(+), Rovsing sign ( + )
• Percussion: tympanic ( + )

• Obturator sign ( + ), Psoas sign ( + )

• Dunphy’s sign ( + )
 Resume
Child, 9 years old, came with sudden persistent abdominal
pain on the right stomach. The patient had anorexia,
nauseous, and vomited one time (liquid substance).

Physical examination findings: tenderness on the right iliac

(+), Blumberg sign (+), Rovsing sign (+), Obturator sign (+),
Iliopsoas sign (+), Dunphy’s sign (+)
 Initial Diagnosis
• Acute right lower quadrant abdominal pain e.c.
suspected appendicitis
 Workups Consideration
Leader Doctors Co-Ass
• Abdominal USG • Abdominal USG
• Complete blood test • Complete blood test
 Diagnostic Findings
• Complete blood count:
• Leucocyte: 17.200(↑)
• Diff count: 0/8/2/72(↑)/29/0
 Diagnostic Findings
• Abdominal USG:
• Appendix was not visualized. Fluid collection were
detected on the RLQ, there was mesenteric
inflammation and multiple mesenteric lymphadenitis
size 1.1 x 0.8 cm. The possibility of appendicitis was
not eliminated
 Working Diagnosis
• Acute right lower quadrant abdominal pain e.c.
suspected appendicitis
 Treatment
Leader Doctors Co-Ass
• IVFD: NS1/2D5 20 dpm • IVFD: NS1/2D5 20 dpm
• Ceftriaxone 2x1g IV • Ceftriaxone 2x1g IV
• Metronidazole 4x200mg IV • Metronidazole 4x200mg IV
• Omeprazole 1x30mg IV • Omeprazole 1x30mg IV
• Paracetamol 4x300mg IV • Ondansetron 2x3mg IV
• Pro laparotomy • Paracetamol 4x300mg IV
appendectomy • Consult to surgeon (to
perform laparotomy
appendectomy)
THANK YOU