MORNING

REPORT
 • Name : Mr. A
• Age : 51 years old
• Sex : Male
• Address : Andaroa Village
• Occupation : Farmer
• Admission : September, 3rd 2019
• DPJP : dr. Syamsul Rijal, Sp. B

IDENTITY
 HISTORY TAKING
• Chief Complain : Pain at right lower quadrant abdomen
• Anamnesis : suffered since 5 hours ago before admitted to hospital,
Pain initially felt in the epigastric region then spreading to the right lower
quadrant of abdomen. pain felt continously. Another complain: nausea
(+), vomit (-), Fever (-), decreased appetite (-), Defecate and Urinate
was normally.
 History of the other diseases :
- There was history of the same complaint before
- There was no history of another disease
- There was no history of previous treatment
 PHYSICAL EXAMINATION

General state
Moderate Illness, Compos mentis, Good Nourish

Vital Sign
BP : 120/80 mmHg
HR : 90x/minutes, regular, strong
RR : 22x/minutes, spontaneous,
symmetric, reguler
T : 37,4◦C
VAS : 6/10
 Head : Within Normal Limit Abdomen : Localized state
Face : Within Normal Limit Upper limb : Within Normal Limit
Eyes : Within Normal Limit Lower limb : Within Normal Limit
Nose : Within Normal Limit
Mouth : Within Normal Limit
Ears : Within Normal Limit
Neck : Within Normal Limit
Chest : Within Normal Limit

PRESENT STATE
Abdominal Region
 INS : Distended (-), follow the motion of breath, , darm contour (-), darm
steifung (-)

 AUS : Peristaltic (+) in the normal limit

 PAL : Pain (+) at right lower quadrant, Defans Muscular (-), rovsing sign (-),
Blumberg sign (-)

 PER : Thympani (+)

LOCALIZE STATE
ALVARADO
SCORE
Manifestations Value
Migration of pain 1
Anorexia 0
Nausea/Vomiting 1
Right lower quadrant tenderness 2
Rebound tenderness 0
Elevated Temperature 1
Leukocytosis 2
Shift of Neutrophils to the left 1
Total 8
Clinical Documentation
 Routine Blood Test
Abdominal Ultrasound

Planning Diagnostic :
• WBC 14.89 x103 / µl
• RBC 5.78 x106/ µl
• HB 16.9 g/dL
• PLT 224 x103/ µl
• Neut 11.96 x103 / uL

• CT 7’50”
• BT 2’38”

Laboratory Findings
RADIOLOGY FINDING

Result:
• Dilatasi usus terlokalisir area Mc Burney,
susp. Causa Appendicitis
 Appendicitis Acute

DIAGNOSIS
 MANAGEMENT
Pharmacological Non-Pharmacological
• IVFD
• Antibiotic
• Rest
• Analgetic • Education
• H2RA

Consult General Surgeon