Case II : ICM 2

A 19 years old man, Mr Yunus comes to Emergency Departement at 11 PM

complaining about whole abdominal pain. It started from pain at right lower quadrant
since 10 days ago, and radiating to whole abdomen since 4 days ago. It is constant in
feature, and increasing from time to time. At first the quality of pain is 4/10, and now
the quality of pain is increasing since 4 days ago, about 8/10. The pain is also
increasing when he coughs or moving his body. Nothing he can do that could reduce
his pain.
The patient is also complaining of fever since 10 days ago, at first it was
intermittent fever with the highest temperature reached at night, and it was
progressing day by day. Last 2 days, the fever became constant.
The abdominal pain and fever is accompanied with vomiting and also
diarrhea. The patient was vomiting 3-4 times a day, the content of the vomit is
indigested food, no blood is in it. The frequency of diarrhea is 5-6 times a day, the
content of the defecation is liquid stool, no blood in it.
The amount of urine is decreased since 2 days ago, it becomes dark, but no
pain in micturition.
His appetite is decreasing since 10 days ago, and he lost weight about 3 kg
within 10 days.
No history of previous abdominal pain. The patient is a labour in factory,, no
history of similar disease in his neighbourhood or his workplace.
He was brought to general practicioner this evening and was given advice to
go to hospital. He never seek medical attention before.
On physical examination: The patient is alert, lethargic, BP 110/70 mmHg,
HR 112x/m, RR 32x/m, Temp 39.00C. The patient is slightly malnourished, his
weight is 54 kg, his height is 168cm. The patient is not anemic and not icteric. Theres
decreased turgor of the skin. Theres is coated tongue. At thoracal region:
symmetrical chest shape and expansion, equal breath sound, no ronchi nor wheezing.
At abdominal region: distended, no bowel sound. Negative liver dullness.
There is tenderness, rebound tenderness, and muscle rigidity at all of abdominal areas.
Punctum maximum of tenderness is at right lower quadrant of abdomen. At digital
rectal examination: normal sphincter tone, the rectal mucosa is smooth, tenderness at
all direction, normal rectal vault, normal prostate. At gloves: theres stool but no
blood is found.

Question to be answered:
1. What has happened to Mr Yunus ?

2. What are the possible causes for his condition?

3. What other examinations (laboratory and radiology) do you need to make a

diagnosis and to seek for complication of the disease?

Laboratory findings:
Hb 11.2 g/dl
Ht 40
WBC 3.500/mm3
Platelet 160.000/mm3
Ureum 88
creatinine 0.8
Sodium 135
Potassium 3.7
Random Blood Glucose 95
Blood Gas Analysis
pH 7.360
pCO2 28
HCO3 18
TCO2 17
BE -6.6
Saturation 97
PT/aPTT Normal
Widal test
Titer of Salmonella typhi-O : 1/320
Titer Salmonella typhi-H : 1/320

5. What is the working diagnosis ?

6. What will you do to provide initial management ? What are your reasons?