EMERGENCY CASE REPORTS

Sunday, November 15th, 2010

SURGERY DEPARTMENT

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
Sunday, November 15th 2010

Ambulation : 2 Patients

Hospitalized : 4 patients

Observation : 1 Patient
Operated : 3 Patients
Death : Patient

Total : 8 patients
 No. 5
Name : Mr. A Sex : Male
Age : 79 years old No. Reg : 44 79 33

Chief complaint : Pain at the whole abdomen wall

History 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 ago

Micturation : Less than normal.
 Physical Examination

General Conditions : Severe illness/ well nourished / conscious

Vital sign : BP : 140/90 mmHg

PR : 120 x/ minutes
RR : 22 x/ minutes
T : 38,5 C
Abdomen
I : Distended, follow of breath motion, no bowel contour, no
bowel movements, no tumor mass.
A : Bowel sound (+), decreased
P : 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
WBC : 13, 53 x 103 / L Natrium : 146 mmol/l

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

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

HCT : 40,0 % HBsAg : Negatif

PLT : 299 x 103 / L Anti HCV : Negatif

CT / BT : 700 / 300 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 : Peritonitis generalisata et causa antrum gastric
DIAGNOSIS perforation

PROGNOSIS : Good

FOLLOW UP : Vital Sign