Patient’s Profile

• A case of TCW , 30 years old, male, married, Roman Catholic, Filipino, born on
October 30, 1990 and currently residing at Sambag 1, Cebu city. He was admitted
to Vicente Sotto Memorial Medical Center on November 3, 2020 at 5:00 PM.
• One day prior to admission, after having his dinner, he experienced sharp,
intermittent pain with a score of 8/10 on Wong Baker Scale at his abdomen which
started at the area around his periumbilical area shifted to right lower quadrant.
• On the day of admission, patient reported increased in severity of sharp-stabbing
pain from 8/10 to 10/10 localized at RLQ; aggravated by movement and not
relieved by positioning or cold/warm compress. Patient verbalized feeling
nauseated. No other symptoms claimed.
• Persistence of symptom prompted consult, thus admission with diagnosis of
appendicitis.
Past Medical History
• The patient denies allergies to any medications, foods or
animals. The patient claims that he only suffered from two
common childhood illnesses, measles and chicken pox, when
he was a 10 and 16 years old respectively.
• Patient has no previous hospitalization and surgeries.
• Patient have no family history of hypertension, diabetes
mellitus, asthma and cancer.
Physical Assessment
Vital Signs are as follows: T- 37.0 degrees C., P- 80 bpm, R- 18 cpm, BP- 130/80 mmHg, Pain- 10/10

• General Appearance. Lying uncomfortably with facial grimace noted, afebrile at 37 degrees Celsius, PERRLA

• Central Nervous System. The patient was alert, coherent, and responsive. Patient is orientated to time, place
and person. Grasps on both left and right hand are strong. His hearing, touch, and smell are relatively normal.
Reported severe pain in RLQ with a score of 10/10.

• Cardiovascular System. Patient’s blood pressure reading was 130/80 mmHg. His pulse was 80 bpm and
respirations were 18 cpm. All extremities are warm to touch. Capillary refill time was less than 2 seconds and a
negative Homan's sign and claudication were noted.

• Respiratory System. Patient’s chest expands symmetrically. Patient breathes shallow & diaphragmatically with
respiratory rate of 18 cpm. Patient was not experiencing any breathing problems and no cough. No wheezing or
stridor noted. No crackles upon auscultation.
• Integumentary system. Patient’s skin is light brown in color, dry, and warm. Has good skin
turgor. The soles and palms of the patient do not exhibit pallor. No clubbing noted and no
palmar erythema observed.

• Musculoskeletal system. Patient has no pain, swelling, stiffness in muscles, joints and back.

• Genitourinary system. Patient normally urinated 3-5x a day, yellow in color, without blood,
foul or frothy smell of urine, verbalized no difficulty and unusual sensations upon urination

• Reproductive System. Patient had his first sexual intercourse at 22 years old and claimed to
have only one sexual partner.
• Gastrointestinal system. Patient’s mouth was dry with no lesions and has no oral prosthesis
worn. No constipation or diarrhea. Abdomen is soft and lax, with right lower quadrant
tenderness. Abdominal examination revealed positive rebound tenderness, positive
McBurney's sign(pain bet. Umbilical and iliac crest) and positive Psoas sign (pain upon leg
elevation)
References:
Aljaber, M. (2017, November 19). Acute appendicitis -Case Presentation. Slideshare.Net.
https://www.slideshare.net/mohammedaljaber7/acute-appendicitis-case-presentation-82316600