팔표용 V2.06. Chief Complaint
“I’m a 31-year-old woman”
“I have pain in lower part of the belly.”
It started this morning at 5am.
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
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