lap jaga appendiks.pptx

8/13/2019 lap jaga appendiks.pptx

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Morning report16th-17thseptember, 2011


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Patient RP, female, 25 years old, came to theemergency unit of AA hospital on september16th 2011

with chief complaint :

Right lower abdominal pain since 2 daysbefore admission


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Present illness history

4 days before admission, patient felt somepain on her upper mid stomach. It was not

changed by meal, not referred, patient nottoo certain felt the pain at this time.

She also complained fever, nauseous and

vomitting. The fever remains steady. Nochange of cycles. She vomitted after everysingle meal, about 4x, with watery andfood contents. No red or dark blood found.


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2 days before admission, patient felt in lower of

stomach but more intensity in lower right of

stomach. It was felt all time, stomach was large

and hard. worsened by cough, changes ofposition and movement.

Mens cycle not well regulated, space betweenmenstruations cycles about 1 month. the

menstrual days just about 2-3 days each cycle

and just drop some bloody. When had

menstruation the pain was not worse.

Then she was taken by her family to see a doctor

and referred to AA hospital.


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Patients urinating : normal, no pain, bloody

or stone in urinating.

Patient not at menstrual condition Trauma history -


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Past illlness history

History of tumor/ cancer on relatives (+)

History of serious illness before (-)

History of appendicitis (-) History of thypoid fever (-)


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History of bloody diarrhea (-)

History of gastric pain (-)

History of traumatic abdominal injury (-) History of any kind of surgery (-)

History of bloody and stone of urine (-)


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General performance

Generalized condition : moderateillness.

Conciousness : composmentis

Vital sign :BP : 110/50 mmHg

P : 100 x/ minutesRR : 23 x/ minutesT : 39,4 0C


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Generalized status

Head and neck : Normal

Thorak : Normal

Abdomen : Localized status

Extremities : Normal

Genitourinary tract : undone

Vaginal/rectal toucher : undone


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Localized status :

Abdomen :

Inspection : abdomen flat, striae alba (+), distention (-),scar (-), darm contour (-), darm steifung (-)

Auscultation : bowel sound (+) increased, metallic sound (-)

Percussion : cant be assessed, there pain in percussion

Palpation : Liver and spleen: cant be asessed Ballotement : cant be asessed muscle rigidity (+), generalized tenderness and rebound tenderness (+) psoas sign (-), obturator sign (+)


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Laboratory Finding

Hb : 10,7 gr%

Leukocyte : 5.800/mm3

Thrombocyte : 269.000/mm3

Hematocryte : 34 vol%

PT : 13,5 s

INR : 1,1 APTT : 35,6 s


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Diagnosis

Peritonitis e.c. ???


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Treatment

Iv line RL 30 dpm

USG of abdominal

Laparatomy explorasi


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THANK YOU

lap jaga appendiks.pptx

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