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BIODATA

Name Age Sex Address Job : Mr. CA : 21 years old : Male : Walikota : Student

Anamnesis
Chief Complaint : Pain on the lower right abdomen since 1 day ago. MOI The patient came to ER because he suffer from intermitten abdominal pain especially on the lower right region since 1 day ago. Its begin from all regio of abdomen, then the pain just in the lower right abdomen. continuously perceived pain and it going worse when the patient cough and move his right leg. Fever (+), nause (-). Vomit (+) 1 times, anorexia (-), pain during urination (-), history of same complaint (-)

Physical Examination
GCS : E4 V5 M6 Vital Sign:
RR BP HR Temp : 18 times per minute : 130/100 mmHg : 98 times per minute : 36,90C

Eye (-/-) Ear Nose Throat

: anemic (-/-), light reflex (+/+), icteric : Normal : Normal : Normal

Thorax
Inspection : chest development simetrics, reguler, abdominothoracal respiration Palpation : vocal fremitus R=D Percusion : sonor (+/+) Auscultation : vesicular (+/+), ronchie (-/-), wheezing (-/-)

Abdomen
Inspection : flat, distended (-), mass (-) Auscultation : peristaltics + normal Palpation : tenderness pain (+) on the lower right quadrant , mass (-), Mc Burney pain of pressure (+), Rovsing sign (+), Bumblerg sign (+) Percusion : timpany sound (+) Psoas Sign (+), obturator sign (+)

Extremity
Look normal Feel normal Move
ROM : normal

Assesment
Susp. Appendicitis akut

Laboratorium
DARAH LENGKAP WBC : 15.8x 103/uL HGB : 16.8 g/dL PLT : 216 x 103/ul

Urinalysis
Sedimen urine Lekosit +1 Protein +1 Keton (-) Urobilinogen normal Eritrosit (-) Lekosit (-) Eritrosit (-) Epitel 2-5/LP

Planning diagnostic
Foto thorax CT/BT

Alvarado Score
Appendicitis point pain Leukositosis (>10.000) Vomitus Anorexia Rebound tenderness Phenomen Abdominal Migrate Pain Degree of celcius (>37,5oC) Observation of Hemogram (segmen >72) Total Point = 8 2 2 1 1 1 1

Working Diagnosis
Acute Appendiscitis

MANTRELS score
M = migration of pain to the RLQ A = anorexia N = nausea and vomiting T = tenderness in RLQ R = rebound pain E = elevated temperature L = leukocytosis S = shift of WBC to the left Total Source.Alvarado, 1986. 1 1 2 1 2 0 7

Treatment
R/ apendektomi Cefotaxim 2x1 gram IV (ST) KTC 3x1 amp iv Ranitidin 3x1 amp iv

TERIMA KASIH