Chief Complaint
Allergy (-)
Asthma (-)
Physical Examination
General state : Moderate sickness
Awareness : Compos mentis
Vital sign :
Temperature: 37C
Pulse: 106x/min
Respiration: 20x/min
Blood Pressure: 126/74
Head : normocephal, no deformity
Eyes : conjungtiva pale -/-, icteric sclera -/-
Lungs : normal breathing sound, rhonki -/-, wheezing -/-
Heart : heart sound is normal, murmur (-), gallop (-)
Abdomen : tenderness in the right iliac fossa, local guarding
and rebound tenderness at the McBurney point, muscular
defense (-), psoas sign (-), rosving sign (-), obturator sign (+)
Extremitas : edema on joints or ankles are absent
DRE : tone of the anal sphincter good, prostate non
palpable, tenderness (-), stool (-), mucous (-), blood (-)
Preoperative
Laboratory (1/3/2015)
Test Result Normal value
Normal heart
Lungs :
infiltrates in left
and right lungs,
especially in
both apex.
Sugestive TBC
Working Diagnosis
Acute Appendicitis
Treatment
Appendectomy cito
Consultation to Pediatric
Antibiotic Ceftriaxone 2x1 gr,
Metronidazole 3x500 mg
Fasting
Operation Report
Allergy (-)
Asthma (-)
Physical Examination
General state : Moderate sickness
Awareness : Compos mentis
Vital sign :
Temperature: 37C
Pulse: 92x/min
Respiration: 20x/min
Blood Pressure: 90/70
Head : normocephal, no deformity
Eyes : conjungtiva pale -/-, icteric sclera -/-
Lungs : normal breathing sound, rhonki -/-, wheezing -/-
Heart : heart sound is normal, murmur (-), gallop (-)
Abdomen : flat, bowel sound (+) normal, palpable pain (-),
hepar lien non palpable
Extremitas : edema on joints or ankles are absent
DRE : tone of the anal sphincter good, prostate non
palpable, tenderness (-), stool (-), mucous (-), blood (-)
Local State
Standart value Result
Darah rutin
Hemoglobin 13,2-17,3 15 g/dL
Hematokrit 33-45 44 %
Leukosit 5.000-10.000 11800/uL
Trombosit 150.000- 267.000/uL
440.000
Fungsi Ginjal
Ureum darah 20-40 34 mg/dL
Creatinin darah 0,6-1,5 0.9 mg/dl
Diabetes
Gula darah Puasa 80-100 95 g/dL
Standart value Result
Fungsi Hati
SGOT 0-34 19 mg/dL
SGPT 0-40 19 mg/dl
Elektrolit
Na 135 147 133
K 3.1-5.1 4.8
Cl 95-108 103
Hemostasis
APTT / control 28.8/31.5 =
0.89
PT / control
12.1/13.5 =
INR
0.89
0.87
Chest
Rontgen
Sight
cardiomegali
Lungs :
infiltrates in
basal right
lungs. Sugestive
Pneumonia
Diagnosis
Hernia scrotalis dextra irreponible
Treatment
Pro herniotomy cito
Ceftriaxon 1x2 gr
Ketorolac 3 x 30mg
Omeperazole 2 x 40 mg
Operation Report
Patient lay in spinal anesthesia
Aseptic and antisepsis eprocedure
was done at the operation field and
the surrounding area
Intruction post op