General Surgery Division

Departement of Surgery
University of Halu Oleo

Abdominal Pain e.c.

Intraabdomen Mass

Presentation by: General Surgery Division

Guided by: “dr. La Ode Rabiul Awal, Sp.B., Subps. BD (K), ”
Emergency Case Report
December 2023
 Patient’s Identity

Name : Ny. S
Age : 72 y.o.
Sex : Female
Addres : Konsel
Religion : Moeslim
Marital status : Married
RM Number : 67 XX XX
 Patient’s History
Main Complaint:
Abdominal paint

Full History:
The patient was admitted with complaints of lower right abdominal pain
since 1 day before entering the hospital. The pain is felt continuously and
gradually gets worse with a sensation like being stabbed, VAS 6/10.
Complaints accompanied by dizziness (+), shortness of breath (+), nausea
(+), vomiting (-), defecation and urination is normal. Previous medical
history: Appendicitis was operated on 12 years ago at the Konawe hospital.
The patient had not taken any medication before entering the hospital, HT(+)
uncontrol, DM (-)
General appearance : Moderate ill
Physical Examination
Consciousness : Compos Mentis (GCS 15,
E4V5M6)
Vital sign :
Blood pressure : 185/98 mmHg
Heart rate : 88 x/minutes
Respiratory rate 22 x/minutes
Temperature 36.0 C
Saturation 95%
VAS : 6/10

Generalization Status
Head: Normochepal
Eyes : Anemic (-), icteric (-), sunset phenomenon (-) pupil isocortical
Nose : Rinorrhea (-), epitaxis (-)
Mouth: stomatitis (-), cyanosis (-),
Neck: KGB enlargement (-),
Thorax: Symmetrical left and right, vesicular breath sounds, wh (-), rh (-)
Abdomen: see Localized Status
Upper extremities: acral warm, CRT < 2 seconds
Lower extremities: acral warm, CRT < 2 seconds
 Physical Examination
Localized Status: Abdominal region
Inspection: convex, follow the movement of breath, A lump
appears in the Mc.Buney region
Auscultation: normal peristaltic sound
Palpation: Mass (+) in the Mc Burney region Uk +/- 2.5x2.5,
elastic consistency, flat surface, regular edge, immobile, tenderness
(+). NTU (+)
Percussion: timpani (+)
 Laboratorium test
Routine Blood Test:
(19/12/2023)
Item Result Units Reference range
WBC 8,7 10^3/µL 4.0-10.0
RBC 4.81 10^6/µL 4,00-6,00
PLT 222 10^3/µL 150 – 400
Hb 14,2 g/dl 12.0-16.0
Hct 40,4 % 37,0-48,0
MCV 84,0 Fl 80.0-97.0
MCH 29,40 pg 26.5-33.5
MCHC 35.1 g/dl 31.5-35.0
 Laboratorium test
Count Type
(19/12/2023)
Item Result Units Reference range
Neutrophils 64.9 % 52.0-75.0
Lymphocytes 22.4 % 20-40
Monocytes 8.9 % 2.0-8.0
Eosinophils 3.2 % 1.0-3.0
Basophils 0.6 % 0.-0.10
 Laboratorium test
Chemical Clinic:
(19/12/2023)
Item Result Units Reference range
GDS 127 mg/dL 70-180
SGPT 35 U/L <31
SGOT 45 U/L <31
Ureum 19 mg/dL 19-44
Creatinin 0.5 mg/dL 0.7-1.2
 Laboratorium test
UrineTest:
(19/12/2023)
Item Result Units Reference range
Warna Kuning Kuning
Glukosa 7’30’’ Mg/dl Negatif
Protein Negatif Mg/dl Negatif
Bilirubin Negatif Mg/dl Negatif
Urobilinogen Negatif Mg/dl Negatif
pH 7.0 Mg/dl <1.0
BJ 1,015 Mg/dl 1.000-1.030
Sedimen
Eritrosit 1-3 HPF

Leukosit 0-2 HPF

Sel Epitel 1-3 lpk

 Radiology

USG Abdomen
Impression:
- Fatty Liver Grade II
- Abdominal Wall Defect (2.5x2.7)
accompanied by organ herniation into the
subcutaneous area in the Mc ragio. Burney dd/
Abdominal Hernia
 Diagnosis
Working Diagnosis: Abdominal pain ec Intraabdominal Mass
 Planning
- IVFD RL 20 tpm
- Drips. paracetamol 1gr/ 8 hours/ iv
- inj. Pantoprazole 40 mg/12 hours/iv
 Thank You
For Your Attention