ASMAD

1 Admission
st

A.H.
54 years old
Female
Muslim
Housewife
Diego Silang, Taguig City
o Chief Complain RIGHT LOWER
QUADRANT
ABDOMINAL PAIN

History of Present Illness

12 hours PTA
o Abdominal Pain

Epigastric Area
Burning in character
Pain scale 5/10
Radiating to the RLQ

o Vomiting x3
ingested food

o Anorexia

previously

History of Present Illness

Few hours PTA
o Persistence of symptoms
o Mefenamic acid temporary
relief

o Consult at AFGH cbc & ua

Hgb
138

Hct
0.42

WBC
9.0

D.
yellow

Cloudy

Acidic

1.020

Seg
0.75

Lym
0.25

Plt 274

Trace

Negativ
e

Abunda
nt

2-4

o Referred to AFPMC
o ADMISSION

PMH
+
Hypertensio
n
maintained
with
Amlodipine
5mg
+
Dyslipidemia
maintained
with
Simvastatin
10mg
No DM

FMH
No
Hypertension
No Diabetes
No Asthma
No Thyroid
disease
No PTB

PSH
Non Smoker
Non Alcoholic
Beverage
Drinker

Physical Examination
GENERA
L
VITAL
SIGNS

HEENT

Conscious Coherent,
Appears weak and in pain
BP: 130/90 PR: 90 RR: 18
T:36.9
Wt: 70kg Ht:
54
Pink palpebral conjunctiva,
anicteric sclerae, no CLAD

CHEST

CARDIO

ABD

Clear breath Sounds,

Symmetrical chest
expansion, no retractions
Adynamic precordium,
normal rate regular rhythm,
no murmurs
Soft flat abdomen with
normoactive bowel sounds;
(+) Direct and Reboud
Tenderness on the RLQ area,

EXT

Full and equal pulses, no

cyanosis, no gross
deformities

ADMITTI
NG
DIAGNOS
IS

T/C ACUTE
APPENDICITIS

INITIAL PLAN
NPO Temporarily
DIET
IV FLUIDS D5 LRS 1L to run for 8 hours

Fast Drip: 200ml now then another

200ml after 30 minutes

LAB TESTS CBC with QPC

PT with INR
Urinalysis
Ultrasound of the Lower Abdomen

MEDICATI Omeprazole 40mg IV OD

ONS
Refer to OB-GYNE for clearance
Others