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Name : Ms. E Sex :Female


Age : 21 yo

Chief complaint : Pain at Right Lower Abdomen

History taking : Suffer since 1 days ago before admitted to ER.


Firstly there is epigastric pain 2 day ago, then it was going to right lower
abdomen.
There is fever, nausea, vomiting (+)
Defecation and Miction within normal.
Fluor Albus (-) Menstruation Period (-)
Symptoms & : Pain at Right Lower Abdomen
sign
Examination : BP 110/80mmHg HR 89x/m
RR 23x/m
T 37.8
Physical Examination
Head and : Anemis -/-, Icteric -/-,
Neck
Thorax : Simetris +/ +
Lung: percussion: sonor/ sonor (-)
breath sound: vesicular/ vesicular
rales -/-, wheezing -/-
Heart: S1S2 single, no murmur, no gallop
Abdomen : Mc Burney: Pain (+) Bloomberg sign (+)
Flank : CVA -/-
Flank Mass -/-
Extremities : Within normal
LABORATORY RESULT
Complete Blood Count

WBC : 17,2 x 103 / μL BT / CT : 3,00’ / 8,00’

RBC : 2,41 x 106 / μL HbsAg : Non Reaktif


HGB : 11,0 g/dL HIV : Non Reaktif
HCT : 22,5 % Na : 132 mmo/L
PLT : 174 x 103 / μL K : 4,1 mmol/L

RBS : 107 mg/dl Cl : 101 mmol/L

BUN : 35,3 mg/dl


Creatinin : 0,6 mg/dl
Laboratories: Urine
Lab Value Normal Value Lab Value Normal Value

Density 1,020 1,003 – 1,30


Epithel - A little
Ketone - Negative
Leucocyte 4-6 10/field
Nitric - Negative
Eritrocyte 0-2 0 – 1 /field
Leuko +
Cylinder - Negative
Hb/Blood - Negative

Color Yellow Crystal - Negative

Clarity Clear Clear


Bacteria +2 Negative
pH 6,0 4,8 – 7,8
Fungi - Negative
Protein - Negative
Glucose - Negative BHCG - Negative
Bilirubin - Negative
Urobilinogen - 3,2
WORKING DIAGNOSIS : Acute Appendicitis

MANAGEMENT : IVFD Maintence RL 20tpm


Ceftriaxone 2x1 gr IV
Metamizole 3x1gr IV
Ranitidin 2x50mg IV
Pro Appendectomy

Co/ Senior General Surgeon


Agree with treatment

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