mr app akut 12 juli

7/28/2019 MR App Akut 12 Juli

1/16

Name : Mr. CA

Age : 21 years old

Sex : Male Address : Walikota

Job : Student

BIODATA


2/16

Chief Complaint :

Pain on the lower right abdomen since 1 day ago.

MOI

The patient came to ER because he suffer fromintermitten abdominal pain especially on the lower right

region since 1 day ago. Its begin from all regio of

abdomen, then the pain just in the lower right abdomen.

continuously perceived pain and it going worse when the

patient cough and move his right leg. Fever (+), nause (-).Vomit (+) 1 times, anorexia (-), pain during urination (-),

history of same complaint (-)

Anamnesis


3/16

GCS : E4 V5 M6

Vital Sign:

RR : 18 times per minute

BP : 130/100 mmHg

HR : 98 times per minute

Temp : 36,90C

Physical Examination


4/16

Eye : anemic (-/-), light reflex (+/+), icteric

(-/-)

Ear : Normal

Nose : Normal

Throat : Normal


5/16

Inspection : chest development simetrics,

reguler, abdominothoracal

respiration

Palpation : vocal fremitus R=D

Percusion : sonor (+/+)

Auscultation : vesicular (+/+), ronchie (-/-),wheezing (-/-)

Thorax


6/16

Inspection : flat, distended (-), mass (-)

Auscultation : peristaltics + normal

Palpation : tenderness pain (+) on thelower right quadrant , mass (-), Mc Burney

pain of pressure (+), Rovsing sign (+),

Bumblerg sign (+)

Percusion : timpany sound (+)

Psoas Sign (+), obturator sign (+)

Abdomen


7/16

Look

normal

Feel

normal

Move

ROM : normal

Extremity


8/16

Assesment

Susp. Appendicitis akut


9/16

Laboratorium

DARAH LENGKAP

WBC : 15.8x 103/uL

HGB : 16.8 g/dL

PLT : 216 x 103/ul


10/16

Lekosit +1

Protein +1

Keton (-)

Urobilinogen normal

Eritrosit (-)

Lekosit (-)

Eritrosit (-)

Epitel 2-5/LP

Urinalysis

Sedimen urine


11/16

Planning diagnostic

Foto thorax

CT/BT


12/16

Appendicitis point pain 2

Leukositosis (>10.000) 2

Vomitus 1

Anorexia -

Rebound tenderness Phenomen 1

Abdominal Migrate Pain 1

Degree of celcius (>37,5oC) -

Observation of Hemogram (segmen >72) 1

Alvarado Score

Total Point = 8


13/16

Acute Appendiscitis

Working Diagnosis


14/16

MANTRELS score

M = migration of pain to the RLQ 1 A = anorexia - N = nausea and vomiting 1

T = tenderness in RLQ 2 R = rebound pain 1 E = elevated temperature - L = leukocytosis 2

S = shift of WBC to the left 0Total 7

Source.Alvarado, 1986.


15/16

Treatment

R/ apendektomi

Cefotaxim 2x1 gram IV (ST)

KTC 3x1 amp iv

Ranitidin 3x1 amp iv


16/16

TERIMA KASIH

mr app akut 12 juli

Documents