BIODATA

• • • • • Name Age Sex Address Job : Mr. CA : 21 years old : Male : Walikota : Student

• MOI The patient came to ER because he suffer from intermitten abdominal pain especially on the lower right region since 1 day ago. anorexia (-). It’s begin from all regio of abdomen. pain during urination (-). Fever (+). Vomit (+) 1 times.Anamnesis • Chief Complaint : Pain on the lower right abdomen since 1 day ago. then the pain just in the lower right abdomen. history of same complaint (-) . continuously perceived pain and it going worse when the patient cough and move his right leg. nause (-).

Physical Examination • GCS : E4 V5 M6 • Vital Sign: – RR – BP – HR – Temp : 18 times per minute : 130/100 mmHg : 98 times per minute : 36.90C .

icteric : Normal : Normal : Normal . light reflex (+/+).• Eye (-/-) • Ear • Nose • Throat : anemic (-/-).

ronchie (-/-). wheezing (-/-) .Thorax • Inspection : chest development simetrics. reguler. abdominothoracal respiration • Palpation : vocal fremitus R=D • Percusion : sonor (+/+) • Auscultation : vesicular (+/+).

distended (-). mass (-) • Auscultation : peristaltics + normal • Palpation : tenderness pain (+) on the lower right quadrant . Rovsing sign (+). mass (-). Mc Burney pain of pressure (+). obturator sign (+) . Bumblerg sign (+) • Percusion : timpany sound (+) Psoas Sign (+).Abdomen • Inspection : flat.

Extremity – Look normal – Feel normal – Move • ROM : normal .

Assesment • Susp. Appendicitis akut .

Laboratorium DARAH LENGKAP • WBC : 15.8x 103/uL • HGB : 16.8 g/dL • PLT : 216 x 103/ul .

Urinalysis Sedimen urine • • • • • Lekosit +1 Protein +1 Keton (-) Urobilinogen normal Eritrosit (-) • Lekosit (-) • Eritrosit (-) • Epitel 2-5/LP .

Planning diagnostic • Foto thorax • CT/BT .

000) Vomitus Anorexia Rebound tenderness Phenomen Abdominal Migrate Pain Degree of celcius (>37.5oC) Observation of Hemogram (segmen >72) Total Point = 8 2 2 1 1 1 1 .Alvarado Score Appendicitis point pain Leukositosis (>10.

Working Diagnosis Acute Appendiscitis .

1986. 1 1 2 1 2 0 7 .—Alvarado.MANTRELS score • M = migration of pain to the RLQ • A = anorexia • N = nausea and vomiting • T = tenderness in RLQ • R = rebound pain • E = elevated temperature • L = leukocytosis • S = shift of WBC to the left Total Source.

Treatment • • • • R/ apendektomi Cefotaxim 2x1 gram IV (ST) KTC 3x1 amp iv Ranitidin 3x1 amp iv .

TERIMA KASIH .