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CASE REPORT

Thursday, November 2th 2015


Team on duty
dr. Rynaldi
(Jaga 1)
dr. Aa Ahmad
(Jaga 2)
dr. T. Ronasky
(Jaga 3)
dr. Andri M
(Jaga 3)
dr. Reza Furqon
(Jaga 4)
dr. Herdi Gunanta S
(Jaga 5)
dr. Avicena Gatot
(Jaga 5)
dr. Ifani
(Jaga 6)
Patient identity
Name
Age
Sex
Address
MR
Phone
Addmission time

: Thamrin
: 60 years old
: Male
: Takengon, Aceh selatan
: 1-06-96-25
: 082361660290
: 10.00 PM

Date/h Examinati Laboratory


Radiology
Hour of Date/ho DPJP
our
on hour
Examination Examination Diagno ur
patien
stics
patient
t came
out
Sen Result Send Result
to ER
from ER
d
Novem
ber 2nd
2015
22.00

22.00

22.10 23.45

22.20 00.15 00.15

Dr. Ferry
Erdani
Sp.B (K)
BD

Chief complaint
Pain at the whole abdominal region
Patient illnes history
The patient was referred from Datu Beurue Takengon district hospital to emergency
room with Pain at the whole abdominal region for 2 days. Initially the patient felt pain at
the epigastrium region for 2 month, patient has history consumed NSAID for more than
5 years, history of nausea and vomiting (-), history abnormality of defecation and
urinate (-).
.

Physical examination
Vital Sign
Blood Presure
: 90 / 70 mmHg
Pulse
: 100 beats / minute
Respiratory rates : 26 breaths /minute
Temperature : 37,6 oC
Localize state :
Abdominal
Inspection
: Symmetrical, distension (+)
Auscultation
: Bowel sound (+) decrease
Palpation
: Muscular rigidity (+), pain at the
whole abdominal region
Percussion
:Tympani (+) Liver dullness (-)

Digital rectal examination


Loose sphincter ani
Empty ampula recti
Smooth mucosa
At glove : faeces (+) blood (-)
IAP : 17 mmHg

Vas Moderate

Assessment
1. General peritonitis due to hollow organ perforation
Dd: - gastric ulcer
- duodenal ulcer
2. SIRS
3. IAH
Management
Stop oral intake
NGT decompression
Oxygen 4 l/minute (nasal canule)
Resuscitation IVFD RL 1000 cc
coloid 500 cc
Fosmicin inj 2 g
Metronidazole drip 500 mg
Omeprazole inj 40 mg
Urine Catheter initial 40 cc
Laboratory examination
Radiology examination
Follow Up
Hour

BP
(mmhg)

HR
(beath/minute

RR
(breath/minute)

Urine

23.00

100/68

114

22

50cc

00.00

105/65

110

24

60cc

01.00

110/68

95

20

70 cc

02.00

110/68

86

22

60 cc

03.00

100/70

96

26

60 cc

04.00

100/60

100

26

50 cc

Laboratory examination :
Hemoglobin

: 15,8 gr/dl

WBC
Platelet
CT/BT
HT
Ureum
Creatinin
Glocouse ad randome
Sodium
Potassium
Chloride

: 16.200 /ul
: 312 x 103/ul
: 7/2
: 47 %
: 110 mg/dl
: 3,27 mg/dl
: 96 mg/dl
: 140 mmol/L
: 4,1 mmol/L
: 111 mmol/L

Thorax Erect
:
pneumoperitoneum at the right subdiafragma
Diagnose
1. General peritonitis due to Gastric perforation
Dd: - gastric ulcer
- duodenal ulcer
2. Severe Sepsis
3. IAH
Consult to digestive surgery division :
Prepared for Laparotomi Emergency
Operative Report :
Midline incision found gastric juice 300 cc sent to Microbiology
Found perforation at the pilorus with diameter 1 cm
Refreshing perforation border biopsy sent to PA
Perforation sutured with omental patch
Performed 2 drainage

Diagnose post operative:


1. General peritonitis due to gastric perforation ICD 10 (CM K65.0)
2. Severe Sepsis ICD 10 (CM R65.2)
3. IAH ICD 10 (CM M79.0)

Follow Up
Date

November Pain
4th
(+)
2015
POD I

General condition:
moderate
Blood Presure: 140/80
mmHg
HR: 90 beats/minute
RR: 20 beats/minute
S/L abdomen
I : Symmetrical,gauze
dry
A: bowel sound (+)
P : Pain (+)
P : Liver dullness (+)
Right Drainage : 200
cc hemorogic serous
Left Drainage : 200
cc hemoragic serous

Post
IVFD RL 20
laparotomy
drip/minute
exploration
Fosmicyn g/12 hour
due to
Metronidazole
1. General
500mg/8 hour
peritonitis due
Omeprazole 80mg /
to gastric
24hour
perforation
Ketorolac 30 mg/8
ICD 10 (CM
hour
K65.0)
NGT Decompression
2. Severe
- Lab examination
Sepsis ICD 10
- Wound care
(CM R65.2)
3. IAH ICD 10
(CM M79.0)