팔표용 V2.0
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A 31-year-old woman presented with worsening lower abdominal pain that started in the right lower quadrant and migrated. On examination, she had direct and rebound tenderness in the right lower quadrant. CT scan showed signs of acute appendicitis. She was diagnosed with acute appendicitis and underwent a laparoscopic appendectomy under general anesthesia.
![Review of System
[General] [GI]
General weakness - Abdominal pain +
Fever - Anorexia +
Chill - Nausea +
Poor oral intake - Vomiting +
[HEENT] Diarrhea -
Headache - [GU]
Dizziness - Flank pain +
[Respiratory] Hematuria -
Cough - Dysuria -
Sputum - Incomplete voiding -
Vaginal discharge +](https://image.slidesharecdn.com/v1-0-110327074017-phpapp01/85/V2-0-20-320.jpg)
![Physical Examination
[Vital sign]
BP: 120/60mmHg, HR: 60 /min, RR: 16 /min, Temp:
36.6℃
[General appearance]
Acutely so ill-looking appearance
[Consciousness level]
Alert
[Chest]
Regular heart beat without murmur
Clear breath sound without rale
[Abdomen]
Abdomen palpation: Soft & Flat
Direct tenderness: + Rebound tenderness: + on RLQ
Bowel sound: normoactive
Rovsing sign: + Psoas sign : - Obturator sign : -](https://image.slidesharecdn.com/v1-0-110327074017-phpapp01/85/V2-0-21-320.jpg)
![[전라도] 여행계획서 V1.0](https://cdn.slidesharecdn.com/ss_thumbnails/v1-0-120227142135-phpapp02-thumbnail.jpg?width=560&fit=bounds)
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팔표용 V2.0
- 2. the case of a woman Group 1 , , , , ,
- 4. Chief Complaint “I’m a 31-year-old woman”
- 5. Chief Complaint “I’m a 31-year-old woman” “I have pain in lower part of the belly.”
- 6. Chief Complaint “I’m a 31-year-old woman” “I have pain in lower part of the belly.” It started this morning at 5am.
- 8. Present Illness Lower abdominal pain
- 11. Present Illness The worst pain Right lower quadrant
- 12. Present Illness The worst pain Right lower quadrant
- 13. Present Illness Last meal and drink yesterday around 8 pm
- 14. Present Illness Last meal and drink yesterday around 8 pm
- 15. Present Illness Last defecation yesterday evening
- 16. History Alcohol 3 times a week 1bottle of soju
- 19. History Family history DM-, HTN-, Tb-, Hepatitis- Allergy none Genital history unmarried Last menstrual period 3weeks ago Last intercourse 1week ago
- 20. Review of System [General] [GI] General weakness - Abdominal pain + Fever - Anorexia + Chill - Nausea + Poor oral intake - Vomiting + [HEENT] Diarrhea - Headache - [GU] Dizziness - Flank pain + [Respiratory] Hematuria - Cough - Dysuria - Sputum - Incomplete voiding - Vaginal discharge +
- 21. Physical Examination [Vital sign] BP: 120/60mmHg, HR: 60 /min, RR: 16 /min, Temp: 36.6℃ [General appearance] Acutely so ill-looking appearance [Consciousness level] Alert [Chest] Regular heart beat without murmur Clear breath sound without rale [Abdomen] Abdomen palpation: Soft & Flat Direct tenderness: + Rebound tenderness: + on RLQ Bowel sound: normoactive Rovsing sign: + Psoas sign : - Obturator sign : -
- 25. Treatment Laparoscopic Appendectomy Under the general anesthesia, a small arcuate infra-umbilical incision is made