IDENTITY

Name : Mrs. E
Age : 27 years old
Address : Lepo-lepo
Admission : Dec, 26th 2018
DPJP : dr. Tedjo Arianto, Sp.B KBD
 HISTORY TAKING
• Chief complain : Abdominal pain at the right lower quadrant
• Anamnesis : (autoanamnesis)
The patient admitted to the Bahteramas Hospital with a complaint
abdominal pain at the right lower area since 2days ago. There was
fever since 3 days ago. other complain from the patient were fever,
anorexia, heartburn every she tried to eat she felt nausea and
sometimes she was vomiting. Defecate and Urinating were good.
There was history same complaint 1 month ago
There was history of medication analgesics and antipiretic
Physical examination

The patient was conscious with moderate ill.

BP = 130/80 mmHg
Pulse = 84x/m, regular, strong
RR = 20x/m, regular
Temperature = 36,9oC
 Generalized status
Head : within normal limit
Face : within normal limit
Eyes : within normal limit
Nose : within normal limit
Mouth : within normal limit
Ears : within normal limit
Neck : within normal limit
Chest : within normal limit
Extremity
Superior : within normal limit
Inferior : within normal limit
Abdomen
Inspection : Flat, follow the motion of
breath, distended (-)
Auscultation : Peristaltic was normal
Percussion : There was tympany
sound and liver deaf
Palpation : Rovsing sign (+) blumberg
sign (+), Psoas sign (+)
Planning :

- Blood routine
- USG abdomen
◦ WBC : 12,86 x 103/uL
◦ HGB : 12,4 g/dL
◦ PLT : 265 x 103/uL
◦ Neut : 11,42 x103/uL
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Clinical Finding
DIAGNOSIS

Acute Appendicitis
MANAGEMENT
• IVFD
• Analgetic
• Antibiotic
• H2 Receptor Agonist
• Consult a Surgeon