morning report acute appendicitis

7/29/2019 Morning Report Acute Appendicitis

1/18

EspridaVandra

Boy


2/18

Patient FR, male, 16 years old, came to the

emergency unit of Arifin Ahmad General hospital

Chief Complain :Pain in the right lower quadrant abdomen since 2

days before admitted to hospital.


3/18

since 2 days before admitted to hospital thepatient complain abdominal pain in the rightlower quadrant. The pain start at middlequadrant of the abdomen and migrating to

the right lower quadrant. The pain describedas sharp pain and continuous. Its becomemore pain if patient walk or move his rightleg. Patient also felt nausea but not vomit (-),anorexia (+), fever (-). Patient didnt got adiarrhea.


4/18

No complain of mixturation, no history ofstone and blood in urine. and no complainabout defecation. Patient went to surgeonclinic and doctor said that patient got an

appendicitis and must get an operation in thehospital. Then patient go to Emergency Unitof Arifin Ahmad General Hospital.


5/18

No history of abdominal traumaNo history of blood and stone in urine

No history of abdominal pain before.


6/18

General condition : looks moderate illness

Counsiousness : Composmentis

Vital signBP : 110/80 mmHg

HR : 96 x/mnt

RR : 18 x/mnt

Body Temp : 36,4C


7/18

Head and neck : Normally

Chest : Normally

Abdomen : Localized statusEkstremity : Normally

Limph node : Normally


8/18

AbdomenInspection : flat shape, scar (-), darm

steifung (-), darm contour (-)

Auscultation : Bowel sounds (+), normalPalpation : tenderness and reboundtenderness in McBurney point,musle rigidity in right lower

quadrant (+), mass (-).Percution : Timpany


9/18

Digital rectal examination Inspection : normal perineum and anal skin,

no discharge or mass.

Palpation : normal anal sphincter tone, smooth

rectal mucous, tenderness in 11 oclock direction Handgloves : faeces (+), blood (-), discharge (-).


10/18

Special Examination

Rovsing sign (-)

Psoas sign (-)

Obturator sign (-) Ballotement (-/-)

CVA tenderness (-/-)


11/18

Working Diagnosis: Acute appendicitis Differential diagnosis:

Illocaecal lymphadenitis

Colitis

Ureter stone


12/18

1. Urinalysis2. Routine blood examination

3. Diff count of white blood cell

4. Abdominal ultrasonography


13/18

Hb : 15,3 gr/dl

Platelet : 310.000/l

Ht : 45,4 %.

WBC : 23.600/l Diff count :

Lymphocyte : 27,5%

Granulocyte : 60,2%

MID : 12,3%


14/18

Macroscopic Colour : yellow Density : clear

Chemical : normally

Microscopic: Glucose : (-) Protein : (-) Sediment :

Erythrocyte : 1-2

Leucocyte : 5-8

Epithel : (+)

Bactery : (+)


15/18

Appendicitis point pain : 2 Leukocytosis : 2

Vomitus : 0

Anorexia : 1 Rebound tenderness phenomenon : 1

Abdominal migrate pain : 0

Degree of celcius (36,40C) : 0

Observation of diff count : 0 Total point : 6


16/18

Acute appendicitis


17/18

Conservative: Bedrest with Fowler position

Ketorolac iv 2 x 30 mg

Cefotaxime iv 2 x 1 mg


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morning report acute appendicitis

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