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