Name: Mr. TSPAge: 21 y.oReligion : MoeslimDate: 15th July 2013Addres: Jl Imam Bonjol RT2 RW5 LamonganNo RM: 20.67.90

GCS : 456 Vital SignBP: 158/90 mmHgPulse: 104x / minutes, regRR: 20x / minutesTemp: 36,5 C

Head and neck: Anemic-/ icteric-/ cyanosis-/ dyspneu -Thorax: simetric bilaterally, retraction (-/-),Pulmo: ves/ves, rh (-/-), wh (-/-)Cor: S1-S2 single, reguler, murmur(-), gallop(-)Abdomen: flat, soepel, abdominal pain epigastric (-), mc burney (+), referred sign (+), meteorismus (-), hepar and lien not palpable, Psoas sign-, obturator sign+Extremity : akral cold, dry, red (+), edema (-/-), CRT < 2RT: Sphinchter ani tight, mukusa smooth, masa-, pain on 9 10, sulcus mediana +, handscoon:blood-, lendir-,feses-

Male, 21 y.oabdominal pain in lower right quadrantVommiting +appitite mc burney (+), referred sign (+)obturator sign+ RT: Pain on 9, 10

Appendicitis acute

Appendecitis acute

PlanningPlanning Dx :-DL, USGPlanning Mx:Chief complaintVital SignLab

Planning Tx :IVFD asering 1500cc/daysInj Metamizole 500mg 3x1 ivInj Ceftriaxone 1x1g ivInj Ondansetron 3x1 (prn)Consul Surgeon Pro Laparostomy

Laboratory FindingsDiff count 4/0/73/17/4Hematocrit 41,7%Haemoglobin 14,6 mg/dLLeukocyte 6.200Trombocyte 208.000SGOT 15SGPT 16GDA 113Bleeding time 130Clothing time 830

Dubia ad BonamExplain to the family about the condition of this patient now, its disease, about its examinations, theraphy and intervention will be done, and also about complication and prognosis. Fasting

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