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Morning Report

3 October 2014
IDENTITY
Name : Mrs. Yuliana Dheku
Age : 27 years old
Sex : Female
Address : Walikota


Anamnesis
Chief Complaint :
abdominal pain
Present illness
Patient come to the hospital because she felt pain
in the right lower abdomen since 2 days ago. Abdominal
pain that she felt was like a terrible tight, became worse
than before. The pain was start from the umbilical and
then migrated to the right lower abdomen. 3 days ago she
also felt pain on her epigastric area. The pain decrease if
she lay down to the right side. Constipation (+) since 7
days ago, fever (+) intermitten, nausea (-), vomiting (-),
anorexia (-), pain during urinate (-), on last day of
menstruation.
Physical Examination
GCS E4V5M6
Vital Sign:
Pulse: 106 times/minute, reguler, RR: 20
x/m, T= 37,4
o
C,
BP: 120/80 mmHg
Eye : anemic (-/-), light reflex (+/+),
icteric (-/-).
Ear : Normal findings
Nose : Normal findings
Neck : Normal findings
Thorax
Inspection : chest development simetrics, regular
Percusion: sonor (+/+)
Auscultation :
Pulmo: vesicular (+/+), ronchie (-/-), wheezing (-/-)
Cor : S1-S2 single, regular, murmur (-)

Abdomen


Inspection : distended (-), syncronized
with breathing
Auscultation : peristaltics sound (+)
normal
Palpation : tenderness pain (+) at the
lower right quadran (McBurney Sign (+)).
Costovertebra angle pain (-), suprapubic
pain (-), defens muscular (-).
Percusion : timpany sound (+)
Rebound phenomen: (+)

Extremity

Look
normal
Feel
normal

Psoas sign (+)
Obturator sign (+)

Rectal Toucher
Patient refused
WBC 15,14 x 10^3/uL
RBC 4,65 x 10^3/uL
Neutrofil 12,62
HGB 12,7 g/dL
PLT 263 x 10^3/uL
Laboratory
Alvarados Score
Migrating Pain 1
Anorexia 0
Nausea 0
Tenderness 2
Rebound 1
Elevated Temperatur 0
Leukositosis 2
Shift to the left 1
+7
Score Interpretation :

1 4 : not an
appendicitis
5 6 : observation
7 8 : appendicitis
>8 :
appendicitis, cito
operation
Planning Diagnostic

suggestion
Abdominal ultrasonography
Assesment
Abdominal pain ec Appendisitis akut
DD: Tractus urinary infection (cystitis or urethritis)
Ovarii cyst




Planning therapy

IVFD RL 30 dpm
Inj. Cefotaxim 2 x 1 gr iv (Skin test)
Inj. Ranitidin 2x1 amp iv
Inj. Metronidazole 500 mg vial by IV
line


THANK YOU

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