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Anna Maryana

Identity Name : Miss Y Sex : Female Age : 15 years old Occupation : Student .

bleeding. She has no hard and pain defecation or diarrhea. She has a normal haid cycle. She feel nauseous and she vomits many times. For the first time. The pain is continuous and increase if she walks. the pain is felt in the epigastrium and it refer to the right lower quadrant of the stomach in several hours. or discharge. The pain comes suddenly. . There is no haid pain. She doesn’t feel chills and fever.Anamnese Autoanamnese on 18 February 2012 Patient complaint that she has have an stomachache over 3 days. She has no hard and pain in urinate.

80C .Physical Examination General State : Moderate Mental State : Compos Mentis Blood Pressure : 120/80 mmHg Heart Rate : 72x/minutes Respiratory Rate : 18x/minutes Temperature : 36.

there is no blood or faeces on hand scoen . Tenderness (-). Psoas Sign (-). Ampulla not collaps. Blumberg Sign (+).5 cm.Localised State a/r abdomen Inspection : flat. Rovsing Sign (+).5x1. imobile Tenderness Mc Burney (+). Obturator Sign (-). Defance Muscular (-) Perkusion : Timpani RT : Sphincter strong. soft Auskultasi : Bowel Sound (+) normal Palpation : Mass in the RLQ(+) size 7. Mucousa smooth. Mass (-). hard.

000 150000 – 450000/ul Pregnant Test - .100 4000 – 10000/ul Trombosit 320.Laboratory PEMERIKSAAN HASIL NILAI NORMAL Hb 12.6 13 .16 g/dl Ht 41 40 – 54 % Leukosit 14.

Working Diagnose Appendicullar Infiltrate .

Treatment Ceftriaxone 1x1g iv Metronidazole 3x500mg drip iv Ranitidine 2x8 mg iv Ketorolac 2x30 mg iv .

Prognose Ad vitam : bonam Ad sanationam : bonam Ad functionam : bonam .