MORNING

CONFERENCE
13-02-2017
L/ML/42YO
Chief Complaint : Pain in the whole
abdomen
It has been suffered by the patient since 1
week ago before admission. Vomiting (+),
nausea (+), history of fever (+), defecate (-)
has been 4 days, flatulence (-), micturition (+)
N. History of previous surgery : (-). History of
NSAID consumption was not clear
History of medication : (-)

History of past illness : (-)

Present State:
Awareness : Alert
Blood Pressure : 130/70 mmHg
HR : 102x/i
RR : 28x/i
Temp : 36,6oc
 Generalized State
Head and neck : no abnormality was found
Chest : no abnormality was found
Abdomen : in localized state
Genitalia : male, no abnormality was
found
Extremitas : no abnormality was found
Localized State
Abdomen:
I : Simetric, distention (+)
P : Defans muscular (+) pain (+) on the whole abdoment
P : Hypertympani
A : Peristaltic (-)

RT : perineum normal, loose of anal sphingter tone,

smooth mucosal layer, pain (+) on the whole clockwise,
ampula recti was filled with feses
Gloves : feses (+), blood (-), mucous (-).
Clinical photos
 Laboratory

• Hb/Ht/WBC/ PLT : 17,0/45,5/17,55/548

• Ur/Cr : 78 /1,07
• SGOT/SGPT : 31/17
• Random blood sugar level : 122
• Na/K/Ch : 122/3,70/105
Chest X-ray
 Working diagnose

Diffuse Peritonitis d/t Hollow Organ Perforation

+ Sepsis
Management in Emergency Room :
• Fasting
• NGT
• Catheter
• IVFD Crystaloid
• inj. Antibiotic
• inj. Analgetic
•Prepare for laparotomy exploration
Durante Operation
THANK YOU