Dr. Moh.

Adjie Pratignyo, SpBA

 DATE OF ENTRY 26/10/18

S:

A 36-years old man comes to the emergency department with

abdominal distention. He complained since three months ago. He
felt no appetite and his body getting thinner. He complained
defecation problem and fever. He denies vomiting, diarrhea,
bloody feces and dysuria. He doesn't have history of
hypertension, diabetic and bleeding disorder.
O:
Vital sign:
Compos mentis, GCS 15
Blood pressure: 110/70 mmHg
Heart rate: 98 times per minute
Respiratory rate: 22 times per minute
Temperature: 36.8 °C
VAS score: 3

Head: CA-/- SI -/-

Thorax: Vesicular +/+ Rh -/- Wh -/-
Heart sound reg +/+ murmur -/- gallop -/-
Extremitas: Oedem -/- CRT<2
Patognomonic examination
 Abdominal
 Inspection:&nbsp; distention
(+)
 Auscultation: bowel sound (+)
 Palpation: abdominal mass
25x15x10 cm, no tenderness
 Percution: dull sound (+)
Kesan: susp Teratoma intra peritoneal
Kesan:
jantung dan paru dalam batas normal
 Hb 9.6
 Leu 8200
 Tro 603.000
 Na 130
 K 3.3
 Cl 97
 Ur 23
 Cr 0.6
 Albumin 1.6
A: Intra Abdominal Tumor

P:
- Inj. Ranitidin 2x1
- Inj. Ondansetron 3x1
- Inf. Paracetamol 3x1
- IVFD RL 16 tpm
- Laparotomy + Biopsy

Plan after surgery:

- Inj. Kalnex 3x1
- Inj. Ceftriaxone 1x2 gr