24-05-2017

DM. Grace dan DM. Ay

 IDENTITY

Name : Ms. M. D. G
Age : 18 years old
Sex : Female
Address : Maulafa
 Anamnesis

Chief Complaint : Right lower quadran abdominal pain
MOI (autoanamnesis and heteroanamnesis)
Patient come to the emergency room with right lower quadran
abdominal pain since 1 week ago. Pain is felt in the middle of the
chest but over time the pain is felt in the lower right abdomen.
The pain disappear-appear. It become more painfull when she
cough or walk, but the pain reduced when she lays down. This
complain is accompanied by a fever that also disappeared-appear
since 1 week ago. In addition to fever, patients also complain of
loss appetite and often feel nauseated but no vomiting.
 Anamnesis

Previous Medical History :The patient has checked
herself 1 week ago in kartini Hospital and based on
the results of the examination the doctor said that
the patient has appendicitis but after returning
home the patient did not continue the treatment
because she felt already better. The patient has
also had a stomach ultrasound examination but
after that the patient does not want to be treated.
 Physical exam

General : Moderately sick
Vital sign
BP : 110/80
HR : 120 x/min
RR : 24x/min
T : 38,3
 Physical exam
Head : normal limits

Eye : anemic (-/-), pupil isokor (+/+), icteric (-/-)
Thorax : chest expansion bilateral simetric, pattern of
respiration is thoracoabdominal
Cor and pulmo : normal limits
Abdomen
I : Flat
A : Peristaltic (+) normal limits
P : Tenderness at the right lower abdomen quadran (+),
mass (-)
P : Tympanic
Extremity : Normal limits
 Physical exam

Alvarado Score :
Migration of pain : 2
Anorexia : 0
Nausea/ vomit : 1
Tenderness in right iliac fossa : 2
Rebound pain : 1
Elevated temperature : 1
Leucocytosis : 2
Shift to the left of neutrophils : 1
 Physical exam

Rovsing sign : (+)
Psoas sign : (+)
Obturator Sign (+)
 Laboratorium
CBC :
Hb 11,6 gr/dL
RBC 4,63 x 10^6/uL
Ht 37,4 %
WBC 20,6 x 10^3/uL H
Plt 314 x 10^3/uL
Neutrophil 17,7 H
 Planning Diagnosis

USG abdomen
 Assessment

Susp. Periappendicular Infiltrat
 Planning therapy

IVFD RL 20 tpm
Infus metronidazole 500 mg IV
Ceftriaxon 2x1 g IV
Diet lunak rendah serat
Bed rest total


THANK YOU