R / Female / 19 yo

May, 27th 2015

 Chief Complaint: Pain on the Right Lower Abdominal

It has been suffered since 4 days before come to

Pirngadi Hospital. initially, The patient come to clinic
and consume antibiotics . Pain is felt to be intermittent.
History of fever (+), nausea (+), vomiting (+). Flatus
(+) Urination (+) Normal.

Previous Disease : Unknown

Previous Medication : Unknown
 PRESENT STATE

Awarness : Alert
Blood Pressure : 110/70 mmHg
Heart Rate : 98 x/min
Respiratory rate : 28 x/min
Temperature : 38.2 C
 PHYSICAL EXAMINATION
Head :
Eye : Conjungtiva anemic (-/-), sklera icteric (-/-)
Ear / Nose / Mouth : in normal limit
Neck : in normal limit
Thorax :
Inspection : symetric
Palpation : Fremitus tactile right = left
Percussion : sonor
Auscultation : vesicular
 Localized state Abdominal
Inspection : Symmetric, distention (-)
Palpation : soepel, pain o/t (R) iliaca region (+)
Percussion : Tympani
Auscultation : Peristaltic (+) N

Digital Rectal Examination :

perineum was normal, anal sphincter tone was tight, smooth
mucosal, rectal ampule feses (+), pain encountered in 10 hours
gloves : faeces/blood/mucus : +/-/-

Superior/Inferior Extremity : Normal

 Laboratory

Hb/Ht/Leu/Tro = 10,00/31,90/12.100/311.000
Kgd ad random = 114 mg/dl
Ureum /creatinin = 12,83/0,67
NA/K/CL = 146/3.50/116
Thorax X-Ray
 Diagnose :
Appendicitis Acute
 Treatment
In Emergency Room
Fasting
IVFD RL 20 drops/min
Inj. antibiotic
Chateter
Patient was prepared for "Appendictomy"
Clinical Photo
Durante Operation
The end,.

Thank you