CASE

REPORT
Tuesday, March 09th 2015
Team in charge
ER :MAN
Ward : NIC
OK : YRM
A.W.S General Hospital
SAMARINDA

Adm. Date :
Nam
:Ny. H
e
Age :31 yo

Chief
complain

Femal
Sex :
e
MR :

: Pain at right Upper abdomen

Hystory
taking

: Pain at right upper abdomen suffered since 4 month before

admitted to Hospital, the pain felt sharp and radiating to the
back of the right shoulder. Initially the pain felt seldomly but
on last week the pain felt more often. Fever (+), Nausea (+),
Vomiting (-). Urine color changed into tea like color, Feces
color is pale.
Examination : Physical examination, Laboratory examination, Radiology
Exam

Physical Examination
Anemic -/- Icteric -/ Thorax : Within normal
limit
Abdomen :
Distended (-)
Tenderness (+) at
RUQ, Murphy Sign
(+), Hepatomegaly
(+),
Tympanic
Bowel Sound (N)
Flank :

Radiologic Examination

LABORATORY
RESULT

Complete Blood Count

WBC

: 20,2 x 103 / L

RBC

: 4,79 x 106 / L

HGB

: 13,9 g/dL

HCT

: 31,7 %

PLT

: 223 x 103 / L

BT / CT

: 200 / 900

Blood Sugar : 95 mg/dl

Ureum

: 23 mg/dl

Creatinin

: 0,9 mg/dl

Complete
Urination Count
BJ
Ketone
Nitrit
Leuko
Hb/blood
Color
Purity
pH
Protein
Glucose
Billirubin
Urobilinog

:
:
:
:
:
:
:
:
:
:
:

1.015
Yellow
Cloudy
6,5
+1
-

Epithel
Leuco
Erytro
Silinder
Crystal
Bacteri
a
Fungi

:
:
:
:
:

+
1-2
2-3
-

: : -

WORKING
DIAGNOSIS

: Diffuse Peritonitis suspect

perforated appendicitis

MANAGEMENT

IVFD RL 2000cc/24 hours

Apply NGT
Apply Urethral catheter
Inj. Ceftriaxone 1 gr / 12 hour
Inj. Ranitidin 50mg / 12 hours
Emergency Laparotomy
exploration
Co/ general surgeon
Agree with treatment