EMERGENCY CASE REPORTS

Sunday, November 15th, 2010

SURGERY DEPARTMENT

EMERGENCY ROOMEMERGENCY ROOMWAHIDIN WAHIDIN

SUDIROHUSODO SUDIROHUSODO GENERAL HOSPITALGENERAL HOSPITAL

MAKASSARMAKASSAR

Sunday, November 15th 2010

AmbulationAmbulation :: 22 PatientsPatients

Hospitalized Hospitalized :: 44 patientspatients

ObservationObservation :: 11 PatientPatient

OperatedOperated :: 33 PatientsPatients

DeathDeath :: PatientPatient

TotalTotal :: 88 patientspatients

No. 5Name : Mr. A Sex : MaleAge : 79 years old No. Reg : 44 79 33

Chief complaint : Pain at the whole abdomen wallHistory taking : Suffered since 2 days before admitted to the

hospital. At the first, patient complained of sudden abdominal pain at the center of abdomen. The pain become worse and followed by bloating, nausea and vomiting. And then he felt pain at the whole abdomen and got fever. He was brought to primary health care and referred to Wahidin Hospital .

Defecation : Never defecation and flatus since 2 days agoMicturation : Less than normal.

Physical Examination

General Conditions

: Severe illness/ well nourished / conscious

Vital sign : BP : 140/90 mmHgPR : 120 x/ minutes RR : 22 x/ minutesT : 38,5° C

AbdomenAbdomen

I : Distended, follow of breath motion, no , no bowel contour, no bowel movements, no tumor mass.

A : Bowel sound (+), decreasedP : Tympani (+), Tapping pain (+)

P : Tenderness (+), Defans muscular (+)

Rectal Toucher

Sphincter ani was loose. Mucous was smooth. Ampula was empty. No palpable tumor mass.

Gloves : feces (-), blood (-), slime (-)

Laboratory Result Laboratory Result WBC : 13, 53 x 103 / μL Natrium : 146 mmol/l

RBC : 4.73 x 106 / μL Kalium : 4, 4 mmol/l

HGB : 13,7 g/dL Chloride : 102 mmol/l

HCT : 40,0 % HBsAg : Negatif

PLT : 299 x 103 / μL Anti HCV : Negatif

CT / BT : 7’00” / 3’00” Uric acid : 9, 7

Blood Sugar : 119 mg/dl Albumin : 2, 6

Ureum : 143 mg/dl

Creatinin : 3, 1 mg/dl

SGOT/SGPT : 104/111 u/l

Thorax AP X-Ray

Abdominal X-Ray Supine Position

Abdominal X-Ray Erect Position

WORKING DIAGNOSIS : Peritonitis generalisata et causa suspect perforation gaster.

MANAGEMENT : O2 IVFD Resuscitation apply NGT and urine catheter Medicamentous Report to senior digestive surgeon : Advice : immediately laparatomy exploration

Operating Procedure• Patient laid supine under epidural and GA• Desinfection & drapping Procedure• Midline incision 2 fingers under Proc. Xyphoideus until 3 fingers upper

SOP• Open peritoneum Identification solid organ seen no abnormallities• Continued with hollow viscous exploration seen anthrum perforation size

1 x 1,5 cm• Stiched perforation with primary suture continued with omental flap• Perform NGT no.18 at gaster and 12 for nutrition at duodenum• Wash peritoneal cavity with normal saline.• Stitch the wound layer by layer and leaving 1 drain• Operation finished

POST OPERATIVE DIAGNOSIS

: Peritonitis generalisata et causa antrum gastric perforation

PROGNOSIS

FOLLOW UP

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Good

Vital Sign