Escolar Documentos
Profissional Documentos
Cultura Documentos
Patient FR, male, 16 years old, came to the emergency unit of Arifin Ahmad General hospital Chief Complain : Pain in the right lower quadrant abdomen since 2 days before admitted to hospital.
since 2 days before admitted to hospital the patient complain abdominal pain in the right lower quadrant. The pain start at middle quadrant of the abdomen and migrating to the right lower quadrant. The pain described as sharp pain and continuous. Its become more pain if patient walk or move his right leg. Patient also felt nausea but not vomit (-), anorexia (+), fever (-). Patient didnt got a diarrhea.
No complain of mixturation, no history of stone and blood in urine. and no complain about defecation. Patient went to surgeon clinic and doctor said that patient got an appendicitis and must get an operation in the hospital. Then patient go to Emergency Unit of Arifin Ahmad General Hospital.
No history of abdominal trauma No history of blood and stone in urine No history of abdominal pain before.
General condition : looks moderate illness Counsiousness : Composmentis Vital sign BP : 110/80 mmHg HR : 96 x/mnt RR : 18 x/mnt Body Temp : 36,4C
Head Chest
and neck
node
Abdomen Inspection
: flat shape, scar (-), darm steifung (-), darm contour (-) Auscultation : Bowel sounds (+), normal Palpation : tenderness and rebound tenderness in McBurney point, musle rigidity in right lower quadrant (+), mass (-). Percution : Timpany
Special Examination Rovsing sign (-) Psoas sign (-) Obturator sign (-) Ballotement (-/-) CVA tenderness (-/-)
1. 2. 3. 4.
Urinalysis Routine blood examination Diff count of white blood cell Abdominal ultrasonography
Macroscopic
: (-) : (-) :
: : : :
Appendicitis point pain Leukocytosis Vomitus Anorexia Rebound tenderness phenomenon Abdominal migrate pain Degree of celcius (36,40C) Observation of diff count Total point
: : : : : : : : :
2 2 0 1 1 0 0 0 6
Acute appendicitis
Conservative:
Bedrest with Fowler position Ketorolac iv 2 x 30 mg Cefotaxime iv 2 x 1 mg