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    Mekong Jumat 22 Desember

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    Sellyma Nora Hasibuan
    The patient, a 37-year-old male, presented with pain across his whole abdomen for 3 days. The pain started in his epigastric region and moved to his right lower abdomen. He had fever, nausea but no vomiting or bowel movements. On examination, his abdomen was tender all over with tympany and decreased bowel sounds. A digital rectal exam found pain on clockwise rotation and feces in the rectum. Laboratory tests and chest x-ray were performed. The working diagnosis was diffuse peritonitis likely due to a perforated appendix. The patient was given IV fluids, antibiotics, and analgesics and prepared for an emergency laparotomy and appendectomy.

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    Mekong Jumat 22 Desember

    Uploaded by

    Sellyma Nora Hasibuan
    16 views14 pages
    The patient, a 37-year-old male, presented with pain across his whole abdomen for 3 days. The pain started in his epigastric region and moved to his right lower abdomen. He had fever, nausea but no vomiting or bowel movements. On examination, his abdomen was tender all over with tympany and decreased bowel sounds. A digital rectal exam found pain on clockwise rotation and feces in the rectum. Laboratory tests and chest x-ray were performed. The working diagnosis was diffuse peritonitis likely due to a perforated appendix. The patient was given IV fluids, antibiotics, and analgesics and prepared for an emergency laparotomy and appendectomy.

    Original Description:

    Difuse peritonitis d/t apendisitis perforasi

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    The patient, a 37-year-old male, presented with pain across his whole abdomen for 3 days. The pain started in his epigastric region and moved to his right lower abdomen. He had fever, nausea but no vomiting or bowel movements. On examination, his abdomen was tender all over with tympany and decreased bowel sounds. A digital rectal exam found pain on clockwise rotation and feces in the rectum. Laboratory tests and chest x-ray were performed. The working diagnosis was diffuse peritonitis likely due to a perforated appendix. The patient was given IV fluids, antibiotics, and analgesics and prepared for an emergency laparotomy and appendectomy.

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    16 views14 pages

    Mekong Jumat 22 Desember

    Uploaded by

    Sellyma Nora Hasibuan
    The patient, a 37-year-old male, presented with pain across his whole abdomen for 3 days. The pain started in his epigastric region and moved to his right lower abdomen. He had fever, nausea but no vomiting or bowel movements. On examination, his abdomen was tender all over with tympany and decreased bowel sounds. A digital rectal exam found pain on clockwise rotation and feces in the rectum. Laboratory tests and chest x-ray were performed. The working diagnosis was diffuse peritonitis likely due to a perforated appendix. The patient was given IV fluids, antibiotics, and analgesics and prepared for an emergency laparotomy and appendectomy.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pptx, pdf, or txt
    of 14

    T/M/37 yo

    Morning Report
    22 Desember 2017
    Chief Complaint : pain on the whole abdomen

    It has been suffered by the patient since 3 days before


    admission to Hospital. Previously patient was feel pain
    on epigastrium then reffered to right lower abdomen,
    but lost arise. Fever (+), nausea (+) vomiting (-), urinate
    (+) normally. Defecation (-) in 1 days. Flatus (+).

    History of previous illnes : not found


    History of drug use: not found
    Present state :
    Awareness : Alert
    BP : 130/80 mmHg
    HR : 84 x / i
    RR : 20 x / i
    T : 38.10C
    VAS :6
    Generalized State
    Head and neck : Abnormality not found
    Chest : Abnormality not found
    Abdomen : in localized state
    Genitalia : male, Abnormality not found
    Extremity : Abnormality not found
    Localized state :
    Abdomen :
    • I : symmetrical, distention (-),
    • P : tenderness (+) o/t whole abdomen,
    • P : tympani
    • A : Peristaltic (+) decreased
    Digital Rectal Examination :
    Perineum normal, Strict anal sphincter tone, smooth
    mucosa, pain (+) on 10 - 12 clockwise, rectum was filled
    with feces,
    Gloves : feses (+), blood (-) mucous (-)
    Clinical Pictures
    Laboratory Findings:
    Hb/Hct/Wbc/Plt : 15.5/43,1/16.20/195
    Neutrophil : 95.30 %
    Ur/Cr : 24/ 0.76
    Na/K/Cl : 143/3,6/113
    Random Blood Sugar : 90
    Chest x-ray
    Working Diagnosis :
    Diffuse Peritonitis d/t suspect Appendix Perforation
    Management in Emergency Room:
    • Fasting
    • IVFD RL 30 gtt/i
    • Insertion urine catheter
    • Inj Ceftriaxone 1 gr/12 h
    • Drip Metronidazole 500 mg/8 h
    • Inj Ranitidin 50 mg/12 h
    • Inj Ketorolac 30 mg/8 h
    • Inj Novalgin 1 amp/12 h (k/p)
    • Patient prepare for laparatomy apendectomy
    Durante operation

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