Case Report and Discussion

 Name : Nn. APW

 Ages : 21 tahun
 Sex : Woman
 Marital status : Not married
 Education : Graduated from Senior High
School
 Address : Semarang
 Job : shop assistant
 Medical Record number: C739629
Anamnesa (Current Disease History)

Since ± 3 days before admission, the patient complains of abdominal

pain in the navel, pain is blunt and felt continuously which is
burdensome if the patient coughs, and at rest pain does not decrease.
Fever (+), fever falls with paracetamol but returns to rise after 8 hours.
Nausea (+) vomiting (-) diarrhea (-) urination no complaints.
Since ± 1 days before admission, pain moves to the lower right
abdomen, pain is blunt and felt continuously, burdensome if the
patient coughs and is more comfortable when bending, temperature
38.5 degrees, nausea (+), vomiting (-) diarrhea ( -), urination has no
complaints, regular menstruation with HPHT 2 weeks ago before
admission, history of intercourse (+) 1 week ago before admission, due
to complaints of pain in the right lower abdomen the patient was taken
to the RSDK Semarang.
Past medical history:
Patients have never had this disease before.
Hypertension (-), DM (-), Asthma (-), surgery history
(-), history of abdominal area trauma (-), history of
kidney stones (-)

Family History:
Families have never had this disease before.

Socio-economic history:
The patient works as a shop assistant. Self financing
Economic impression is enough.
 General condition: Looks moderate ill
 Vital sign
 RR = 20x/mnt (regular, adequate depth of breath)
 HR = 103x /mnt (regular, adequate tone and volume)
 BP =105/67mmHg (93 mmHg)
 GCS = E4M6V5 =15
 t = 38C
 VAS =4
 Head : mesosefal, skin turgor normal
 Eye : anemic conjungtiva (-/-), icteric sklera (-/-)
sunken eyes (-/-)
 Mouth : dry lips(-)
Lung :
 I : Static : right hemithorax = left hemithorax
 Dynamic : right hemithorax = left hemithorax
 Pa : right tactile fremitus = left tactile fremitus
 P : Sonor inall around area
 A : Vesicular basic sound, additional sound (-)

Heart:
 I :Ictus cordis unseen
 Pa :Ictus cordis palpated 5th ICS, at medial midclavicle line
 P : normal configuration
 A : Pure heart sound
Abdomen :
 I :flat, bowel movement(-),bowel pattern (-)
 Pa : pain tenderness (+) in the right lower abdomen
especially in Mc Burney, rebound tenderness (+), defans
muscular (-), Rovsing sign(-)
 Pe : tympanic, liver dullness (+), flank pain (-/-),
shifting dullness (-), pain on percussion (-)
 Au :Bowel sound (+) normal

Dunphy Sign (+)

Obturator sign (-)
Psoas sign (-)
Supra pubic pain tenderness (-)
Extremities : Upper Lower
 cyanosis -/- -/-
 cold acral -/- -/-
 deformities -/- -/-
 motoric 555/555 555/555
 sensoric + +

Rectal toucher :
 TSA (+), the mucosa is slicky, there is no mass / tumor, the
ampulla recti does not collapse, there is no tenderness (-).
Stool (+), mucus (-), blood (-), pain tenderness At 10
o’clock
Working Diagnose:
 Suspect Acute Appendiccitis
 DD/ UTI
Disturbed ectopic pregnancy
Ureterolithiasis
Initial Management:
 IpDx :
S : -
O : Alvarado score, complete blood count, differential
white count, uric acid, urinalisis, dipstik, hCG urine test,USG
 IpRx : -
 IpMx : General condition, vital sign, VAS, symptom of acute abdomen
 IpEx :Diagnosis, examination plan, operation plan and risk , prognosis
 Migration of pain 1
 Nausea and vomitting 1
 Anorexia 0
 Tenderness in RLQ 2
 Rebound pain 1
 Elevated Temperature 1
 leukocytosis no data
 Shift to the left no data

 Score : 6  Observation