Part I

Data
Nama : Agus
Age : 35 years
Sex : Male
Ethnic group : Tionghoa
Religion : Katolik
Education : Bachelor in Education
Occupation : Bussiness
Address : Medan
Nationality : Indonesia
Marital status : Menikah dengan 2 anak
Provisional Diagnosis : Acute Appendicitis
Operative Procedure : Laproscopic Appendectomy

Health history of patient

Keluhan utama:
Pain abdomen since 2 days back(peri umbilical pain and later right side pain
more than left)
1 episode of fever upto 101F
1 episode of vomitting

Present history:
Patient complaints of acute abdomen pain (generalised) since evening a day
back.The pain was associated with an episode of fever and vomitting diminished by
medicine later on.
Later on the pain persist on the right illac fossa of the patient so he was brought to
the hospital for further management.

Socio-economic history: He belongs to a middle class family. He is the bussiness man

and the bread owner of the family.
Personal History: He has no any history of allergy toward drugs and any foods. He is
non drinker and smoker.
Medical surgical history: No history of tuberculosis, diabetes and hypertension .He
had not any infectious disease like HbsAg, HIV or STI.
He has no any history of medical illness like T.B, asthma, renal disease,
hypertension, heart disease etc.
He was admitted at hospital for ureteroscopy for UTI (urinary tract infection) for a
day 1 year back.
Family history: There was no significant history of chronic and hereditary disease;
chronic illness.His mother was operated cholecystectomy for cholelithiasis almost a
year back.
Health seeking practice: He belongs to the urban area of Medan. Though, they
believed in both traditional healer and hospital treatment. So if anybody in the
family gets ill they first go to the hospital first but also believe intraditional healers.
Personal health history: Non smoker and Non alcoholic. No any food taboos practice
in his family/home. So he eats every kind of food everyday.
Environmental factors: they live in urban setting in Medan with well accesibility of
health facilities, education, water supply, and other facilities.
3 storyed houses with7 rooms, separate kitchen and seperate sanitary laterine.

Physical examination of the patient

It is an important tool of assessing the patients health status and about 15% of the
information used in assessment comes from the physical examination.
The methods that I have applied in the physical examination of the patient are:
Measurement
Smelling
Inspection
Palpation
Percussion
Auscultation

Vital sign
Temperature: 99F
Pulse: 92/min
Respiration: 20/min
Blood Pressure: 120/80
Measurement:
Height: 5 ft 4 inches
Weight: 56kg
General Appearance:
He can walk straight (gait). His general state of health is normal. He appears healthy, well
nourished. His reaction is appropriate to the stimuli. Hygiene and cleanliness are
maintained.
Head to toe examination:
1. Head and face: Round and symmetrical. Condition of the scalp is clean and color and
texture of hair is black and silky. Any injury is not present, no swelling, no tender shape
is round and face is in round shape.

2. Eyes: discharge absent, movement-bilateral equal movement, color of conjunctiva-

normal, pink, color of sclera- white, transpired, pupil- normal in size and good reaction to
light and no any abnormality found.
3. Ears: Cleanliness- clean, discharge- absent but slightly wax present, pain not found,
Hearing problem- no, lymph node are not palpable.

4. Nose: Location-centrally located, deviation- not deviated septum, blockage- not

found, and injury- not presents, bleeding- not present, polyps- not present and infections
not present.

5. Mouth, throat and neck: Lips- no cracks, looks pink, gums- not swelling and bleeding
present, buccal mucosa is pink in color, not any sore or rashes present, no missing teeth,
Tongue- normal, moist, no sore present, maxillary lymph node is not palpable, cervical
lymph node are not palpable, thyroid glands are not enlarged, Neck is freely movable and
tonsils is normal and not any redness or enlargement.

6. Chest and lungs: Size, shape and symmetry are normal, chest movement is bilateral
equal, respiratory rate is normal, dysponea, cough, haemoptysis, cyanosis are absent,
resonant sound found all over the lungs area and no any dull sound on
percussion, wheezing, crept sounds are absent, normal breathing sound is present on
auscultation and no any abnormality found.

7. Abdominal examination:
A) Inspection- normal oval in shape
B) Palpation-slightly tenderness in the right illac fossa.Presence of rebound tenderness.
C) Auscultation- On auscultation normal bowel sound heard

8. Cardiovascular system: pulse-92/min, BP-120/80 mmofhg, heart sound is normal

sound (lub-dub) present on auscultation.

9. Musculoskeletal system: Muscle weakness is absent, joint pain or stiffness is absent,

edema on joints or ankles are absent and any other fracture or deformity is not found.

10. Genitourinary system: No any discharge present.normal external genitalias