24-05-2017

DM. Grace dan DM. Ay

 IDENTITY

Name : Mr. L.D
Age : 24 years old
Sex : male
 Anamnesis

Chief Complaint : Right lower quadran abdominal pain
MOI (autoanamnesis)
Patient come to the emergency room with right lower
quadran abdominal pain since in the morning 07.00 am.
Pain is felt in the middle of the abdominal but over time the
pain is felt in the lower right abdomen. The pain disappear-
appear. It become more painfull when he walk, but the pain
reduced when he lays down. This complain without by a
fever. Patients also complain of nauseated and vomited
once time. The contenst of vomit is food he has been eaten.
 Anamnesis

Previous Medical History : -
 Physical exam

General : Moderately sick
Vital sign
BP : 110/70mmHg
HR : 96 x/min
RR : 22x/min
T : 36
 Physical exam
Kulit
pucat (-), ikterik (-)

Head : normal limits
Eye : anemic (-/-), pupil isokor (+/+), icteric (-/-)
Telinga : perdarahan (-)
Hidung : perdarahan (-)
Mulut : mukosa bibir lembab, pucat (-)
Leher: pembesaran KGB (-)
 Physical exam
Thorax :

Paru
I : gerakan dada simetris (+), pattern of respiration is
thoracoabdominal
P : Nyeri tekan (-) taktil fremitus simetris kiri=kanan
P : Sonor pada seluruh lapangan paru
A : vesikular (+/+), rhonchi -/-, wheezing -/-
Cor : S1S2 tungga regular, murmur (-), gallop (-)
 Physical exam

Abdomen
Inspeksi : cembung, distensi (-)
Auskultasi : bising usus (+) kesan normal
Palpasi : nyeri tekan Right lower quadran (+),
nyeri tekan Mc Burney (+) lien dan hepar tidak
teraba, defans muscular (-) Nyeri ketok ginjal (+/-)
Perkusi : hipertimpani(+)

Ekstremitas
Akral hangat, CRT <2 detik, edema (-)
 Physical exam

Alvarado Score :
Migration of pain : 1
Anorexia : 1
Nausea/ vomit : 1
Tenderness in right iliac fossa : 2
Rebound pain : 0
Elevated temperature : 0
Leucocytosis : 0
Shift to the left of neutrophils : 0
 Physical exam

Rovsing sign : (-)
Mc burney sign (+)
Psoas sign (+)
Obturaror sign (-)
Blumberg sign (-)
 Laboratorium
CBC :
Hb 15,6 gr/dL
WBC 13,3 x 10^3/uL
Plt 257 x 10^3/uL

Urinalisis
Clear, Leukosit esterasi (-), keton (-), Glukos(-), blood
+1,
 Planning Diagnosis

USG abdomen
Abdomen x-ray
 Assessment

Susp. Apendisitis acute dd urinary tract stones
 Planning therapy

IVFD RL 20 tpm
Ranitidine 2x50 mg IV
KTC 2x30mg IV


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