1. Mrs. Rumiatun / 48 y.o / 10.63.71.38 / dr.

ODI, SpOG
(S) The patient was consulted by a surgeon colleague with a suspected perforated
appendicitis dd/ TOA; P1001; Married 1x  17 years; Youngest living Child : 16 years;
Contraception: (-); LMP: April 10th, 2022; Menarche: 14 y.o.; Cycle : 25-28 days;
duration 5 days; volume 3-4 diapers/day (O) General Status: GCS 456 A(-)/I(-)/C(-)/D(-);
BP: 100/60, HR: 72, RR: 20; Trect: 36,8oC, Sp.O2: 98% (free air); Cor: WNL; Pulmo:
WNL; Abdomen : defans (+), NT (+) especially in the RLQ area, McBurney sign (+), BU
(+); Gynecologi status: Inspeulo  P: closed, smooth, fluor (-); V/V flx (-), flr (-) CU :
AF, WNL; AP D/S : massa -/-, nyeri -/-; CD WNL RT : TSA (+), smooth mucosa; US:
Currently there is no clear appearance of appendicitis, the possibility of retrocaecal
appendix cannot be ruled out. Ascites. Currently the liver / spleen / GB / uterus / bilateral
adnexa / right and left kidneys / pancreas do not show abnormalities. Uterus AF measures
4.78x3.3 cm, ET (+) 0.26 cm. No mass was found in both adnexa. Free fluid in the
Douglas cavity (+) and hepatorenal (+); Swab ID Now : Negative; CXR : WNL;
Laboratory : Hb 16,1; Hct 50,3; WBC 33.500; PLT 536.000; Na/K/Cl 141/3,5/104;
HbsAg/ AntiHIV NR/NR; Alb 3,82; GDA 242; BUN/SK 14/ 1,04; SGOT/ SGPT 26/37;
Bil total 0,45; CRP 0,9; PPT/ APTT 16,2/ 30,0; PP test: negatif (A) SOT susp malignancy
+ Ascites + Anemia (Hb 9,1) + Hypoalbuminemia (Alb 2,58) (P) General stabilization,
preparation for surgery.