7. Mrs. Risma/30 yo/August 25th 2013 at 22.

30
Chief Complain : Right lower abdominal pain
History :
Since 1 day before admission, patient complained about
stomach pain in the right quadrant which appeared suddenly
and intermitten. The chief complain wasnt accompany with
fever, nausea, vomitting, and decreasing of eat appetite.
Patient had a same complain history since 1 month ago and
hospitalized at Ansari Saleh Hospital for 5 days. The chief
complain reappeared 2 days ago and patient gone to Poli
Ginecology and Poli Surgery at Ulin General Hospital, the
result wasnt abnormality. Patient had known for having cyst
history and shes mestruating now.
General status
Alert
Vital sign :
BP : 110/80 mmHg - T : 36,6
0
C
RR : 20 x/minute - HR : 78
x/minute

Eye : anemic conjunctivae (-/-), icteric sclerae (-/-)
Mouth : wet mucous,
Neck : increase of JVP (-), enlargement of limph node
(-)
Head/Neck
I : symmetric respiratory movement, retraction (-),
laceration (-)
P : symmetric VF
P : Sonor in all lung field
A : symmetric VBS, Rh (-/-), Wh (-/-)
Chest
Anemic (-) edema (-), parese (-)
Extremities
Secondary Survey
Abdomen :
I : Flat and soft
A : normal bowel sound
P : H/L/M not palpable,
tenderness (+) in RUQ,
epigastrium, RMQ, RLQ.
P : tympanic in all quadrants

Rectal Tousse :
Tonus sphincter ani strong,
clear mucose, skibala palpable,
ampula recti isny colaps

Handscun :
Faeses (+), blood (-)








Clinical Picture
Laboratory (RS Ulin 26
th
Agt 2013, 02:55)
Pemeriksaan Nilai Rujukan
Hemoglobin
13,1 12,00-16,00 g/dl
Leukosit
17,6 4,0-10,5 ribu/ul
Eritrosit
4,46 3,90-5,50 juta/ul
Hematokrit
38,6 37,00-47,00 Vol%
Trombosit
442 150-450 Ribu/ul
RDW-CV
14,3 11,5-14,7 %
MCV
86,7 80,0-97,0 fl
MCH
29,3 27,0-32,0 pg
MCHC
33,9 32,0- 38,0 %
Gran %
72,3 50,0-70,0 %
Linfosit %
19,8 25,0-40,0 %
MID %
7,9 4,0-11,0 %
GDS
144 < 200 mg/dl
Laboratory (RS Ulin 26
th
Agt 2013, 02:55)
Pemeriksaan Nilai Rujukan
PT
9,9 9,9-13,5 detik
INR
0,88
APTT
25,3 22,2-37,0 detik
SGOT
28 0-46 U/I
SGPT
30 0-45 U/I
Ureum
17 10-50 mg/dl
Creatinin
0,5 0,7-1,4 mg/dl
Natrium
139,5 135-146 mmol/l
Kalium
3,6 3,4-5,4 mmol/l
Chlorida
110,4 95-100 mmol/l
Laboratory (RS Ulin 26
th
Agt 2013, 02:55)
Pemeriksaan Nilai Rujukan
URINALISA
Warna Kekeruhan
Kuning - keruh Kuning-jernih
BJ
1.030 1.005-1.030
pH
6,0 5.0 -6.5
Keton
Negative Negative
Protein Albumin
Trace Negative
Glukosa
Negative Negative
Bilirubin
Negative Negative
Darah Samar
+ 3 Negative
Nitrit
Negative Negative
Urobilinogen
0,2 0,1-1,0
Leukosit
Negative Negative
Laboratory (RS Ulin 26
th
Agt 2013, 02:55)
Pemeriksaan Nilai Rujukan
URINALISA (Sedimen)
Leukosit
1-23 0 3
Eriythrosit
Many 0 2
Selinder
Negative Negative
Epithel
1 + 1 +
Bakteri
1 + Negative
Kristal
Negative Negative
Lain-lain
Negative Negative
Rontgen (RS Ulin 26
th
Agt 2013)
Thorax AP
USG Appendix, adnexa, and uterus
(RS Ulin 25
th
Agt 2013)
Impression:
- Periappendicular mass ec.
Inflamation
-- Renal bilateral, VU, and
uterus doesnt have any
abnormality.
-- Ascites (-)

Working Diagnosis
Obs. Stomach pain ec. periappendicular mass
ec. inflamation
Management
Obs. TNRS
IVFD RL 20 gtt per minute
Fasting (+)
Pro exploration laparatomy cito