Академический Документы
Профессиональный Документы
Культура Документы
ACUTE APPENDICITIS
Created by :
Elmer Basila 1215107
Friska MB 0915175
Kisyana FK 1115196
Tutor:
dr. Eduard P. Simamora, Sp.B, Sp.BA
SURGERY DEPARTMENT
FACULTY OF MEDICINE MARANATHA CHRISTIAN UNIVERSITY
IMMANUEL HOSPITAL
BANDUNG
2017
I. Patient’s Identity
Patient’s name : R. J. P
Gender : Male
Age : 11 years
Nationality : Indonesian
Address : Bandung
Sent from : Emergency Room (October 9th, 2017)
Entry diagnosis : Acute Appendicitis
Examination date : October 9th, 2017
II. Anamnesis
Heteroanamnesis from his mother
Chief Complaint: Right Lower Quadrant abdominal pain
Client was administered to Immanuel Hospital ER by his parents because client complaining
about abdominal pain especially in Right Lower Quadrant area since yesterday, the pain is
persistent and unbearable that client can barely slept at night, client felt nauseous and migrating
pain from epigastric area about 12 hours before Right Lower Quadrant pain. Client hasn’t felt
any fever, vomiting, client having appetite problem in past 2-3 days
Client was born at 38 weeks of gestational age at hospital, with birth weight 287 kg and birth
height 53 cm. client has complete immunization.
Physical Examination (October 9th, 2017)
• General Appearance : good
• Consciousness : compos mentis
• Weight : 36 kg
• Vital Sign:
• Pulse : 89x/min
• Respiration : 18x/min
• Temperature : 36,3⁰C
• Skin : anemic (-), cyanotic (-), icteric (-)
• Hair : black, heavy, not easily revoked
• Head : normal
• Eye : conjunctivae not anemic, sclerae not icteric, palpebrae not
swollen
• Ear, Nose, Throat : nostril breathing -/-, mucus -/-, blood -/-
• Mouth : lip not cyanotic, wet mucosa, T1 / T1, pharynx not hyperemia
• Neck : no lymph node enlargement, trachea on central position.
• Chest : symmetric shape and movement on both side
• Heart : normal heart sound, regular
• Lungs : VBS +/+, ronchi -/-, wheezing -/- , slyme -/-
• Abdomen : bowel sound (+) >>, defance muscular (+), mc burney tenderness
(+)
• Genital : scrotum : testis -/-
• Anorectal : no examination procedure done
• Extremities : warm, CRT < 2”
III. Resume
Client has Right Lower Quadrant abdominal since 1 day ago, persistent and unbearable. Client
feeling nauseous, and the pain was migrating from epigastric area to Right Lower Quadrant, and
decreased in appetite .Client has no fever. no complains to urinating and defecation.
Medication : appendectomy
• Differential count:
Basophil :0.9
Eosinophil :1.1
Staff Neutrophil :0 (low)
Segemented Neutrophil :78.8 (High)
Lymphocytes :15.2 (High)
Monocytes :4
• Urinalysis
Within Normal Limits