IDENTITY

Name
: Mrs. M
Age
: 34th years old
Gender
: Female
Address
: Butung Village
Responsibility doctor
: dr. Faruly Wijaya,
Sp.B
Date of entry
: Saturday, October17th 2015

ANAMNESIS
Chief complaint : abdominal pain
Anamnesa : suffered since 5 days before admitted to the
hospital. Pain started in the lower-abdominal region and then
on the all region of abdominal. The pain was constantly, blunt,
and aggravated by change of position. There was vomitting
one times. The vomitt is including leftovers and water. The
patient felt anorexia and the patient was diarrhea for a few
days. In one day, the patient's diarrhea is more than 5 times.
She got fever since 4 days ago. The urine was normal.

History: there is a history of curretage after she give birth

one week ago by midwife.

PHYSICAL EXAMINATION

GS : Medium ill, Conscious

Vital sign

BP

: 100/60mmHg

Breathing

Heart rate : 102x/m

Temperature : 37,2 0c

: 22x/m

General state

Head : There is no abnormality

Eyes
: There is was anemis Conjuntiva
Nose
: There is no abnormality
Ears : There is no abnormality
Neck : There is no abnormality
Thorax

I : Simetrical movement and no

retraction.
P : vocal fremitus is simetric.
P : resonant sounds on the lung.
A : vesicular sound was founded and no
additional sound.

Abdomen
I : Distented, follow teh motion of breath
A : Peristaltic was decreased
P : Tympany, liver deaf was difficult founded,

word of pain.
P : There is defans musculer, tenderness all
region.

Digital Rectal Touche

Anal

sphincter no strangle

Rectal

mucosa slick

Rectal

ampulla not collapse

No

tenderness, no mass

Release:

stool (+), mucus (-), blood (-)

DIAGNOSED
PERITONITIS CAUSED BY UTERI PERFORATION

Plan of check
Daily blood
USG abdomnal

Plan of therapy
Fluid therapy
Analgesic
drugs
Antibiotic
drugs
Consult

LABORATORY FINDINGS

WBC : 35,78 103/uL

HB : 7,7 g/dL
PLT : 594 103/uL
Neut. : 92,4 %

GDS : 101 mg/dL

Ureum : 75 mg/dL
Crea. : 1,3 mg/dL

USG Abdominal
Tampak echo cairan bebas
disertai septasi
Dilatasi loop-loop usus
Hepar, GB, Lien, pancreas DBN
Uterus : ukuran besar, tampak
multipel lesi hiperechoic pada
area cavum uteri
Kesan:
Tanda-tanda peritonitis
Dilatasi usus
endometritis