3. Ch.Khairi Ghani/ 5 y.o/MR 1.43.50.

96
Admitted on July 27th 2019 at 10.00 pm
Chief Complain : Pain on the right lower abdomen
History :
he complained pain on her right lower abdomen since 2 day before admission. Pain
was felt firstly at epigastric region and referred to right lower abdomen. Pain was felt
like stabbing sensation and accompanied with nausea especially after he drank or
ate therefore he lost of appetite in the last 2 days. he got fever 12 hours ago. His last
defecation was yesterday and there wasn’t blood and diarrhea. He could urinate
normally and there wasn’t history of dysuria, passing stone, and abdominal trauma.
He never complained about mass in his abdomen and loss of weight.

History of Past Illness : -

History of Family Illness : -
 Vital sign
oHR : 116 tpm (strong and regular pulse)
oRR : 22 tpm
oTemp : 38 C
oSpO2 : 99% without O2 supply
oWeight : 14 kg
 • pale conjungtiva (-/-), sclera icteric (-/-), pupil equal 3mm/3mm, light reflex (+/+),
Head/Neck sunken eyes (-/-)

• I : symmetric respiratory movement, retraction (-), bruise (-)

• P : symmetric vocal fremitus
Chest • P : sonor at all lung fields
• A : vesicular breath sound, rhonchi (-), wheezing (-)

• I : distension (-), flat, mass (-), venectation (-)

• A : bowel sound (+) 6 x/minute
Abdomen • P : Tenderness (+) a/r MC burney and umbilicus, rovsing sign (-), blumber sign (-),
defans muscular (-). liver, spleen, mass not palpable
• P : tympani (+)

Extremities • warm extremities in all regio, parase (-), edem (-), CRT <3 s
Alvarado Score :
• App. Point pain 2
• Leucocytosis 2
• Vomitus 0
• Anorexia 1
• Rebound tenderness 0
• Abdominal migrate pain 1
• Degree of celcius 1
• Obs hemogram (N >72%) 1
• Total 8
Clinical Picture
 Laboratory Findings 27/07/2019
Examination Result Normal Value

Hemoglobin 12,4 12,00-16,00 g/dl

Leukosit 13,6 4,0-10,5 ribu/ul

Eritrosit 4,42 3,90-5,50 juta/ul

Hematokrit 34,9 37,00-47,00 vol%

Trombosit 317 150-450 ribu/ul

RDW-CV 12,4 11,5-14,7 %

MCV 79,0 80,0-97,0 fl

MCH 28,1 27,0-32,0 pg

MCHC 35,5 32,0- 38,0 %

 Urinalysis Finding 27/07/2019
Examination Result Normal Value

Colour Yellow Yellow

Clarity Clear Clear

pH 6.0 5.0-6.5

Ketones 1+ Negative

Protein-Albumin Negative Negative

Glucose Negative Negative

Bilirubin Negative Negative

Occult Blood Negative Negative

Nitrite Negative Negative

Urobilonogen 0.1 0.1-1.0

Leukocyte Negative Negative

 Urinalysis Finding 27/07/2019
Examination Result Normal Value

Leukocyte 0-1 0-3

Eritocyte 0-1 0-2

Ephitel 1+ 1+

Crystal Negative Negative

Bacteria Negative Negative

 Diagnosis
Abdominal pain e.c. Susp. Acute Appendicitis
 Management
Treatment in ER :
• IVFD D5 ½ NS 1200 cc
• Inj ceftriaxone 2 x 700 mg
• Inj ranitidine 2 x 20 mg

Consult to Pediatric Surgery:

• Pro appendectomy

Patient out by request