S/F/31yo

S/F/31yo

Chief complaint: Pain on the whole abdomen

The pain has been suffered by the patient since 1 days before admission to Haji Adam Malik Hospital. Firstly, pain was feel in epigastrium and spread into whole abdomen. Fever (-), nausea (+), vomiting (+). Micturation (+), defecation (-), flatus (+).

Present state : •Awareness : Alert •BP : 110/80 mmHg•HR : 85x/i •RR : 22x/i •T : 36,8°C •VAS : 5

Generalized State :

• Head and neck : no abnormality was found • Chest : no abnormality was found

• Abdomen : in localized state

• Genitalia : male, no abnormality was found

• Extremities : no abnormality was found

Localized State :• Abdomen :I : Symmetry, Distention (+)P : pain on the whole abdomen, muscular rigidity (+) P : tympaniA : Peristaltic decrese

• DRE : Perineum usual, loose anal sphincter tone, ampulla was not filled faeces, smooth mucous, pain (-). Hand gloves : feces (-), blood (-), mucous (+).

Laboratory findings:

• Hb/Hct/WBC/PLT : 13,7/41,7/15,1/281• Na/K/Cl : 130/3,4/104• Ur/Cr : 15,1/0,61• Random Blood Glucose :132,3• Albumin : 3,1

Chest X-ray

Working Diagnose:• Diffuse Peritonitis d/t susp. Appendicitis

perforation

Treatment• Nill Per Mouth• NGT insertion, came out greenish fluid 50cc• Urine catheter insertion, came out initial clear

yellow urine 100cc• IVFD Crystalloid • Antibiotic Injection • Analgetic injection• Patient was prepared for appendictomy

laparotomy

Cranial

In Operating theater• Patient in supine position in General anasthesia ETT, aseptic, antiseptic procedure • Midline incision, Cutis, subcutis, fascia, peritoneum was opened came out serous

haemorrhage about 500 cc• Identification of hollow organ, gaster, jejenum, ileum in normal limit• Appendix, colon, and sigmoid in normal limit• Identification pancreas, found expand pancreas, sofonifikasi was found, necroticans

pancreas was not found• Fluid came from retroperitoneal• Identification gynecology organ, found ovarium cyst size 5 cm consult at durante to

Obgyn department drealing was performed• Bleeding control• Abdomen fluid was evacuate intermittenly, leaving 2 drain for external draining• The surgical wound was closed layer by layer• Operation was done