Patient With Acute Appendicitis

Patient

Sex: Male

Ethnic Group: Malay

Age: 14 years old

Ward: Surgical Ward 18, Hospital Taiping

Occupation: Student

Marital Status: Single

Date of Admission: 12th November 2015

Chief Complaint(s)

He is admitted to the ward with the chief complain of pain at right lower quadrant of the abdomen for 8 hours prior to his admission.

History of Presenting Illness

This was his second episode since 10 days ago where he develop the same pain at his right flank. He suddenly experienced severe pain 8 hours before admission when the pain shifts to his right lower quadrant of his abdomen. The onset is at 6.30 am before worsening at 10 p.m to 2 p.m. He described the pain as continuous sharp pain and gradually increased in severity. There is no radiation of the pain. The pain was exaggerated on movement and touch. There were no relieving factor and he scale the severity as 7/10. He experienced fever for 1 day prior to admission. It was a mild grade continuous fever. He does not experienced chills and rigor. The patient does not experience any nausea or vomiting, no dysphagia, no pain during micturition and no alteration in bowel habit. He experienced loss of appetite but not notice any weight loss.

Systemic Review

Central Nervous System: He doesn’t have any parasthesia and no experienced of unconscious or fits. He doesn’t have any weakness of limbs and no hearing problems as well as visual disturbance.

Cardiovascular System: He does not experience any chest pain or palpitation. He does not have dyspnea or leg swelling.

Respiratory System: He does not have shortness of breath, no cough and no hemoptysis.

Genitourinary system: He doesn’t have pain during urinating and no increase of passing urine and he doesn’t need to get up in the middle of the night to pass urine. There is no blood in the urine.

Musculoskeletal system: He doesn’t have any stiffness and swelling at any joints. He can walk normally and never had history of falls.

Endocrine system: He doesn’t have any intolerance towards hot and cold. He doesn’t have any excessive thirst.

Other: He doesn’t have any skin rash or any bleeding or bruising at any part of his body.

Past Medical History

This is his first admission to the ward after having his second episode of the same pain. The first episode was 10 days prior to his admission. The first episode was relieved after taking pain killer at the clinic.

Past Surgical History

The patient does not have past surgical history.

Drug History

He is not currently on any medication.