Patient A.C.

18 years old, came in from the emergency room at 8:13AM due to severe
right lower quadrant pain with a pain scale of 10/10. He was febrile at 39 degrees Celsius since
4:00AM, RR at 26, PR 90, BP 130/90. He was ordered with stat ultrasound, urinalysis and
CBC and VS every 4 hours.
The ultrasound revealed appendicitis, The urinalysis; color: yellow; pH: 8 (5-9);
leukocytes: negative; protein: trace; glucose: negative; ketones: negative; blood: negative;
specific gravity: 1.031 (1.005-1.030); RBC: 0-2hpf; Pus cell; TNTC. Complete blood count
revealed; WBC: 15,000 (5,000-10,000); RBC: 5.31 (male: 4.7-6.1; female: 4.2-5.4);
hemoglobin: 14.17 (male: 14-18g/dL; female: 12-16g/dL); hematocrit: 42% (male: 42-52%;
female: 37-47%); platelet: 194,000 (150,000-350,000).
The patient was endorsed by the ER nurse. The surgeon came at 8:24AM and
ordered for “STAT” appendectomy. Patient ordered NPO. The procedure and situation
were explained to the patient and relatives as well as the risk and advantage of the
procedure. Informed consent preceding to the procedure to be secured. The surgeon ordered to
inform the anesthesiologist on duty and the OR, IVF of PNSS 1L x 8 hours, Cefuroxime
750mg IV ANST 30 minutes prior to OR.
The patient then transferred to operating room via stretcher at 8:33AM. The patient
was endorsed to the Operating Room Nurse with a skin test due at 9:00AM.