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CASE NO.

-1

Name Gugulothu Somla DOA 12/1/2008


Age 50 yrs DOO 12/1/2008 8.30 pm
Sex Male DOD 25/1/2008
ResidenceNalsyagal thanda Result Relieved
Kodakandla mandal Regd.No. 1448
Occupation
Farmer
Complaints
1.Pain abdomen since 9 hrs

HISTORY OF PRESENT ILLNESS


A.Pain 1.onset Acute
2.duration since 9 hrs
3.location situated at first in epigastrium
4.radiation radiated to all over the abdomen
5.character dull aching
6.nature continuos
B.Vomitings 1.number
2.colour no vomitings
3.character
4.quantity
C.Bowels 1.frequency once only
2.diarrhea nil
3.blood & mucus nil
4.malena nil
5.haematemesis nil
PAST HISTORY
1.History suggesting peptic ulcer Present
2.Duration of symptoms 6 yrs
3.Periodicity Present
4.Pain in relation to food intake relieved after food
5.History of drug ingestion brufen tab on and off for body pains
6.Associated symptoms
a)vomitings nil
b)haematemesis nil
c)malena nil
7.Any serious previous illness nil
8.Operation no
9.Loss of weight no
10.Diabetes mellitus no
11.Enteric fever no
12.Cardio vascular disease no
PERSONAL HISTORY
1.Appetite Good
2.Diet Non vegetetarian and chilly food
3.Micturition Normal
4.Bowels regular
5.Sleep disturbed due to pain
6.Addictions
a)alcoholism on and off
b)smoking ten cigarettes daily since 30 yrs
c)chewing tobacco no
FAMILY HISTORY Nil particular
TREATMENT HISTORY takes Digene syrup and tab Rantac at the time of pain

GENERAL EXAMINATION

A.General Appearance
1.Built Moderate
2.Pallor Absent
3.Dehydration Severe
4.Eyes Sunken
5.Tongue Pink
6.Teeth Normal
VITAL DATA
1.Pulse 98 /min Regular
2.Temparature Normal
3.Respiration 31 /min
4.B.P. 15/90 mmHg
B.Abdominal examination
INSPECTION
a)Shape of abdomen Distended
b)Movement of abdominal wall with respiration Restricetd in the upper part
c)Hernia sites Normal
PALPATION
a)Tenderness All over the abdomen
b)Gaurding All over the abdomen
c)Muscular rigidity In epigastrium.rt.hypochondrium
d)Rebound tenderness Present
PERCUSSION
1.Liver dullness Obliterated
2.Shifting dullness Present
AUSCULTATION
1.Bowel sounds Sluggish
SYSTEMIC EXAMINATION
a)Heart S 1 S 2 Heart normal
b)Lungs Clinically clear
c)CNS No neurological deficit
d)Spine normal
e)Scrotum normal
PROVISIONAL DIAGNOSISPeritonitis due to duodenal ulcer perforation
INVESTIGATIONS
1.Urine
a)Albumin Trace
b)Sugar Nil
2.Hb% 76%
3.Blood urea 18 mg
4.Blood sugar 90 mg Random
5.Blood group AB + ve
6.Plain X-ray abdomen erect posture Gas under diaphragm
No 3852 Date 12/1/2008
TREATMENT
1.Preoperative
a)Nothing by mouth
b)Ryel's tube aspiration
c)Intravenous fluids
d)I.V.Antibiotics
e)No enema
2.Anaesthesia General Endo Tracheal
3.Operation text
a)Incision Upper mid line Laporotomy
b)Findings
1.Exudate 800 ml of frank pus
2.Perforation In anterior wall of First part of Duodenum
Size 3 mm Shape Round
PROCEDURE
Perforation is closed with 3 simple intermittent 2-0 silk sutures and reinforced
with omental patch.Peritoneal toilet done with normal saline .Compleete
haemostasis secured.Wound closed in layers after keeping in flanks
bilateral abdominal drains.
POST OPERATIVE PERIOD Uneventful
Naso Gasric aspiration,antibiotics,analgesics,and I V Fluids
Recovery from Paralytic Ileus48 Hrs
Drains removed 5 th day

COMPLICATIONS
Post operative fever Nil
Wound infection Nil
Post operative vomitings Nil
Suture removal 10 th post operative day
Discharged on 13 th post operative day
Hospital stay 12 days
Interval between onset of symptoms and surgery Eleven hours
Follow up Followed up for one and half yrs,and patient was problem free
CASE NO.-2

Name P.Narender DOA 18/1/2008


Age 33 yrs DOO 19/1/2008 1.50 am
Sex Male DOD 29/1/2008
ResidenceKagipally Result Relieved
Jayapur Mandal,Adilabad Regd.No. 2180
Occupation Farmer
Complaints Pain since evening of 18/1/08

HISTORY OF PRESENT ILLNESS


A.Pain 1.onset Sudden
2.duration Since 6 hrs
3.location started in epigastrium later on
4.radiation To all over abdomen
5.character Piercing and constant
6.nature Continuos
B.Vomitings 1.number
2.colour
3.character No vomitings
4.quantity
C.Bowels 1.frequency
2.diarrhea Nil
3.blood & mucus Nil
4.malena Nil
5.haematemesis Nil
PAST HISTORY
1.History suggesting peptic ulcer Absent
2.Duration of symptoms
3.Periodicity Nil
4.Pain in relation to food intake Nil
5.History of drug ingestion Analgesics for five days prior to admission
6.Associated symptoms
a)vomitings Nil
b)haematemesis Nil
c)malena Nil
7.Any serious previous illness Nil
8.Operation Nil
9.Loss of weight Nil
10.Diabetes mellitus Nil
11.Enteric fever Nil
12.Cardio vascular disease Nil

PERSONAL HISTORY
1.Appetite Loss of appetite since one week
2.Diet Mostly vegetarian with plenty of chillies
3.Micturition 4/1 normal
4.Bowels Regular
5.Sleep Normal
6.Addictions
a)alcoholism Occasionally Beer & whisky
b)smoking No
c)chewing tobacco No
FAMILY HISTORY Nil particular
TREATMENT HISTORY Irregular use of antacids and H 2 receptor
antagonist
GENERAL EXAMINATION

A.General Appearance
1.Built Moderate
2.Pallor No
3.Dehydration Severe
4.Eyes Sunken
5.Tongue Dry & pink
6.Teeth Normal
VITAL DATA
1.Pulse 110 mm Regular
2.Temparature Normal
3.Respiration 32 / min
4.B.P. 150 /90
B.Abdominal examination
INSPECTION
a)Shape of abdomen Distended
b)Movement of abdominal wall with respiration Normal
c)Hernia sites Normal
PALPATION
a)Tenderness All over abdomen
b)Gaurding All over abdomen
c)Muscular rigidity Rt.Hypochondrium
d)Rebound tenderness Present
PERCUSSION
1.Liver dullness Obliterated
2.Shifting dullness Present
AUSCULTATION
1.Bowel sounds Sluggish

SYSTEMIC EXAMINATION
a)Heart Normal
b)Lungs clinically clear
c)CNS Normal
d)Spine NAD
e)Scrotum Normal
PROVISIONAL DIAGNOSISAcute perforation of Duodenal ulcer with Peritonitis
INVESTIGATIONS
1.Urine
a)Albumin Nil
b)Sugar Nil
2.Hb% 78%
3.Blood urea 24 mg
4.Blood sugar 86 mg
5.Blood group O +ve
6.Plain X-ray abdomen erect posture Gas under diaphragm
No. 4217 Date 18/1/08
TREATMENT
1.Preoperative
a)Nothing by mouth
b)Ryel's tube aspiration
c)Intravenous fluids
d)I.V.Antibiotics
e)No enema
2.Anaesthesia General Endo Tracheal
3.Operation text
a)Incision Upper Mid line Laporatomy
b)Findings
1.ExudateOne Litre bile stained fluid in peritoneal cavity
2.Perforation 0.5 cm size oval shaped in anterior wall of first part of
duodenum.
PROCEDURE
Simple closure of perforation with omental patch of Graham method with 2-0
Mersilk sutures.Peritoneal toilet done ,compleete haemostasis secured.
Wound closed in layers after keeping bilateral abdominal drains
in flanks
POST OPERATIVE PERIOD
Naso gastric Aspiration,Antibiotics,Analgesics,and IV Fluids

Recovery from Paralytic Ileus48 hrs

Drain removed 4 th post operative fluid


COMPLICATIONS
Post operative fever No
Wound infection No
Post operative vomitings Present 4 th & 5 th days,relieved with RTA and anti emetics
Suture removal 7 th post operative day
Discharged on 11 th post operative day
Hospital stay 11 days
Interval between onset of symptoms and surgeryseven hours
Follow up For one and half years with out complications
CASE NO.-3

Name Allepu Ballaiah DOA 21/2/2008


Age 55 yrs DOO 22/2/08 1.00am
Sex Male DOD 28/2/2008
ResidenceKannure Result Relieved
Kamalapure,Mandal,Karimnagar(Dist) Regd.No. 6437
Occupation
Agriculture Labour
Complaints
Pain abdomen 10 and half hours

HISTORY OF PRESENT ILLNESS


A.Pain 1.onset Acute
2.duration Since 10 &1/2 hrs
3.location Rt hypochondrium initially referring to Rt shoulder
4.radiation To all over abdomen
5.character Burning initially,dragging later on
6.nature Continuos
B.Vomitings 1.number
2.colour
3.character No vomitings
4.quantity
C.Bowels 1.frequency
2.diarrhea No
3.blood & mucus No
4.malena No
5.haematemesis No
PAST HISTORY
1.History suggesting peptic ulcer Present
2.Duration of symptoms 3 yrs
3.Periodicity Present
4.Pain in relation to food intake Relieved after taking food
5.History of drug ingestion Brufen on & off for body pains
6.Associated symptoms H/O bronchial ashma on anti ashmatics for 15 yrs
a)vomitings Nil
b)haematemesis Nil
c)malena Nil
7.Any serious previous illness Nil
8.Operation Nil
9.Loss of weight Nil
10.Diabetes mellitus Nil
11.Enteric fever Nil
12.Cardio vascular disease Nil

PERSONAL HISTORY
1.Appetite Normal
2.Diet Vegetarian with plenty of chillies
3.Micturition Normal
4.Bowels Normal
5.Sleep Normal
6.Addictions
a)alcoholism 500 ml country liquor for 25 yrs
b)smoking 5 chuttas daily
c)chewing tobacco No
FAMILY HISTORY Nil particular
TREATMENT HISTORY Antacids and Rantac tabs for past 3 yrs.

GENERAL EXAMINATION

A.General Appearance
1.Built Thin
2.Pallor No
3.Dehydration Severe
4.Eyes Sunken
5.Tongue Dry & pink
6.Teeth normal
VITAL DATA
1.Pulse 90 min
2.Temparature Normal
3.Respiration 22 /min
4.B.P. 110 /60 mmHg
B.Abdominal examination
INSPECTION
a)Shape of abdomen Distended
b)Movement of abdominal wall with respiration Restricted
c)Hernia sites Normal
PALPATION
a)Tenderness Diffuse tenderness all over abdomen
b)Gaurding All over abdomen
c)Muscular rigidity All over abdomen
d)Rebound tenderness Present
PERCUSSION
1.Liver dullness Obliterated
2.Shifting dullness Present
AUSCULTATION
1.Bowel sounds Absent

SYSTEMIC EXAMINATION
a)Heart Normal
b)Lungs Cl.Clear
c)CNS Normal
d)Spine Normal
e)Scrotum Normal
PROVISIONAL DIAGNOSISPeritonitis due to duodenal ulcer Perforation
INVESTIGATIONS
1.Urine
a)Albumin Nil
b)Sugar Nil
2.Hb% 76%
3.Blood urea 24 mg
4.Blood sugar 146 mg
5.Blood group AB +ve
6.Plain X-ray abdomen erect posture Gas under diaphragm
No. 2461 Date 21/2/08
TREATMENT
1.Preoperative
a)Nothing by mouth
b)Ryel's tube aspiration
c)Intravenous fluids
d)I.V.Antibiotics
e)No enema
2.Anaesthesia General Endo Tracheal
3.Operation text
a)Incision Upper Midline Laporatomy
b)Findings
1.Exudate2 Litres of yellowish green fluid
2.Perforation 4 mm Size perforation on the anterior wall of first part of
duodenum
PROCEDURE
Perforation closed by Graham's omental patch using 2-0 silk sutures.Peritoneal
toilet done with 2 litres of normal saline.After securing haemostasis wound
closed in layers after keeping abdominal drains in both the flanks
POST OPERATIVE PERIOD
Naso gastric Aspiration,Antibiotics,Analgesics,and IV Fluids

Recovery from Paralytic Ileus48 hrs

Drain removed 5 th post operative fluid

COMPLICATIONS
Post operative fever 3 rd & 4th th POD,relieved with anti-pyretics
Wound infection No
Post operative vomitings No
Suture removal 8 th POD
Discharged on 9th POD
Hospital stay 9days
Interval between onset of symptoms and surgery21 hours
Follow up For one and half year,Patient had stich abscess one month
after discharge ,drained wound healed well,asymptomatic
after that.
CASE NO.-4

Name kammala Narayana DOA 24/2/2008


Age 60 yrs DOO 25/2/08 3.PM
Sex Male DOD 5/3/2008
ResidenceMenazipet,Muttaram(mandal) Result Relieved
Karimnagar(Dist) Regd.No. 6768
Occupation Agriculture
Complaints 1.Pain abdomen since 5 days
2.Not passing urine since 1 day

HISTORY OF PRESENT ILLNESS


A.Pain 1.onset Acute
2.duration For the past five days
3.location Initially in epigastrium
4.radiation all over the abdomen
5.character Piercing and aching
6.nature Constant
B.Vomitings 1.number
2.colour
3.character Absent
4.quantity
C.Bowels 1.frequency
2.diarrhea Nil
3.blood & mucus Nil
4.malena Nil
5.haematemesis Nil
PAST HISTORY
1.History suggesting peptic ulcer Old case of chronic duodenal ulcer
2.Duration of symptoms 6 yrs
3.Periodicity Present
4.Pain in relation to food intake Relieved after food intake
5.History of drug ingestion Rantac tabs antacid syrup
6.Associated symptoms
a)vomitings Nil
b)haematemesis Nil
c)malena Nil
7.Any serious previous illness Nil
8.Operation Nil
9.Loss of weight Nil
10.Diabetes mellitus Nil
11.Enteric fever Nil
12.Cardio vascular disease Nil

PERSONAL HISTORY
1.Appetite Normal
2.Diet Veg & Non-Veg ,plenty of chillies
3.Micturition Oliguria since 1 day,before normal
4.Bowels Regular
5.Sleep Normal
6.Addictions
a)alcoholism Toddy 1 litre once in 4 days since 35 yrs
b)smoking 2-3 cigerattes per day
c)chewing tobacco yes
FAMILY HISTORY Nil Particular
TREATMENT HISTORY Antacids irregular

GENERAL EXAMINATION

A.General Appearance Patient is in shock,peripheries cold


1.Built Average
2.Pallor No
3.Dehydration severe
4.Eyes Sunken
5.Tongue Dry
6.Teeth Normal
VITAL DATA
1.Pulse 128 /min feeble
2.Temparature 98 ⁰F
3.Respiration 38/min shallow
4.B.P. 80/60 mmHg
B.Abdominal examination
INSPECTION
a)Shape of abdomen Grossly distended,skin shiny
b)Movement of abdominal wall with respiration Diminished Movement
c)Hernia sites Normal
PALPATION
a)Tenderness Present in all quadrants more in Rt.Hypochondrium
b)Gaurding Present
c)Muscular rigidity Present in all quadrants more in Rt.Hypochondrium
d)Rebound tenderness Present
PERCUSSION
1.Liver dullness Not obliterated
2.Shifting dullness Present
AUSCULTATION
1.Bowel sounds Absent

SYSTEMIC EXAMINATION
a)Heart Normal
b)Lungs Bilateral crepts and wheeze present
c)CNS Normal
d)Spine Normal
e)Scrotum Normal
PROVISIONAL DIAGNOSISDuodenal ulcer perforation with peritonitis
INVESTIGATIONS
1.Urine
a)Albumin Nil
b)Sugar Nil
2.Hb% 78%
3.Blood urea 26 mg
4.Blood sugar 86 mg
5.Blood group O + ve
6.Plain X-ray abdomen erect posture Gas under dome of diaphragm
No. 880 Date 24/2/08
TREATMENT
1.Preoperative
a)Nothing by mouth
b)Ryel's tube aspiration
c)Intravenous fluids
d)I.V.Antibiotics
e)No enema
2.Anaesthesia General Endo Tracheal
3.Operation text
a)Incision Upper Midline Laporatomy
b)Findings
1.Exudate 5 litres bile stained purulent fluid
2.Perforation 1.5 cm in size on the anterior surface of first part of
duodenum
PROCEDURE
After draining peritoneal fluid ,perforation was closed with 2-0 mersilk with
omental patch.Peritoneal toilet done with normal saline ,haemostasis secured.
wound closed after keeping abdominal drains in both flanks.
POST OPERATIVE PERIOD
Resuscitation of shock
NG Aspiration,High Antibiotics,IV Fluids
Recovery from Paralytic Ileus48 hrs
Drain removed On 7 th post operative day

COMPLICATIONS
Post operative fever Present
Wound infection No
Post operative vomitings No
Suture removal Alternate sutures on 7 th day,remaining on 9 th post operaive
Discharged on 10 th post op day
Hospital stay 10 days
Interval between onset of symptoms and surgeryFive and half days
Follow up For one and half yrs,without complications
CASE NO.-5

Name B.Janardhan DOA 5/3/2008


Age 45 yrs DOO 6/3/2008 12.40am
Sex Male DOD 11/4/2008
ResidenceLaxmidevpet,Venkatapure(mandal) Result Relieved
WarangalDist. Regd.No. 8117
Occupation
Agriculture
Complaints
1.Pain abdomen since 3 days
2.Distension of abdomen since 3 days
3.constipation since 2 days

HISTORY OF PRESENT ILLNESS


A.Pain 1.onset Sudden onset since 3/3/08
2.duration 3 days
3.location First in epigasrium Rt hypochondrium later
4.radiation to Rt.iliac fossa
5.character Piercing
6.nature continuos increasing inn intensity
B.Vomitings 1.number
2.colour
3.character no vomitings
4.quantity
C.Bowels 1.frequency Constipated since 2 days
2.diarrhea No
3.blood & mucus No
4.malena No
5.haematemesis No
PAST HISTORY
1.History suggesting peptic ulcer No
2.Duration of symptoms No
3.Periodicity No
4.Pain in relation to food intake No
5.History of drug ingestion No
6.Associated symptoms
a)vomitings No
b)haematemesis No
c)malena No
7.Any serious previous illness No
8.Operation No
9.Loss of weight No
10.Diabetes mellitus No
11.Enteric fever Pulmonary TB 5 yrs back
12.Cardio vascular disease No

PERSONAL HISTORY
1.Appetite Normal
2.Diet Mixed with plenty of chillies
3.Micturition Normal
4.Bowels constipated for 2 days
5.Sleep Normal
6.Addictions
a)alcoholism Toddy 1 litre per day since 10 yrs
b)smoking 10 beedies daily 10 yrs
c)chewing tobacco No
FAMILY HISTORY Nil particular
TREATMENT HISTORY Nil particular

GENERAL EXAMINATION

A.General Appearance
1.Built Average
2.Pallor No
3.Dehydration Severe
4.Eyes Sunken
5.Tongue Dry & pink
6.Teeth Normal
VITAL DATA
1.Pulse 100 min Regular
2.Temparature Normal
3.Respiration 34 /min
4.B.P. 110 /90
B.Abdominal examination
INSPECTION
a)Shape of abdomen Distension of abdomen present
b)Movement of abdominal wall with respiration Less in upper abdomen
c)Hernia sites Normal
PALPATION
a)Tenderness In all quardrants
b)Gaurding Rt Hypochondrium
c)Muscular rigidity Rt.Iliac fossa
d)Rebound tenderness Present
PERCUSSION
1.Liver dullness Obliterated
2.Shifting dullness Present
AUSCULTATION
1.Bowel sounds absent

SYSTEMIC EXAMINATION
a)Heart Normal
b)Lungs Cl.Clear
c)CNS Normal
d)Spine Normal
e)Scrotum Normal
PROVISIONAL DIAGNOSISAcute Duodenal ulcer Perforation with Peritonitis
INVESTIGATIONS
1.Urine
a)Albumin Trace
b)Sugar Nil
2.Hb% 80%
3.Blood urea 28 mg
4.Blood sugar 72 mg
5.Blood group A + ve
6.Plain X-ray abdomen erect posture Gas under dome of Diaphragm
No. 1062 Date 5/3/2008
TREATMENT
1.Preoperative
a)Nothing by mouth
b)Ryel's tube aspiration
c)Intravenous fluids
d)I.V.Antibiotics
e)No enema
2.Anaesthesia General Endo Tracheal
3.Operation text
a)Incision Upper Midline Laporatomy
b)Findings
1.Exudate 2 Litres of purulent bile stained fluid
2.Perforation 5 mm Size perforation on the anterior wall of 1 st part of
Doudenum
PROCEDURE
Simple closure of perforation with 2-0 silk,with omental patch.Peritoneal toilet done
with 2 litres of normal saline,Wound closed in layers after keeping bilateral flank
drains.
POST OPERATIVE PERIOD
NasoGastric aspiration,Antibiotics,IV Fluids

Recovery from paralytic Ileus After 72 hrs

COMPLICATIONS
Post operative fever No
Wound infection Present,Pus for C/S,E.Coli grown, sensitive to ciprofloxacin
Post operative vomitings No
Suture removal 9 th post op day,wound gaping closed by secondary suturing
Discharged on 11/4/2008
Hospital stay 34 days
Interval between onset of symptoms and surgery 82 hrs
Follow up Monthly follow up for six months ,with no problems,lost for further follow up
CASE NO.-6

Name Chintala Keshavulu DOA 7/3/2008


Age 30 Yrs DOO 7/3/2008 12.00pm
Sex Male DOD 20/3/08
ResidenceJangalapally,Mulugu(mandal) Result Relieved
Dist.Warangal Regd.No. 8270
Occupation
Agriculture
Complaints
1.pain abdomen since 2 days
2.Vomiting since morning
3.Distension of abdomen since morning

HISTORY OF PRESENT ILLNESS


A.Pain 1.onset sudden and spontaneous
2.duration since 48 hrs
3.location First in epigastrium
4.radiation To all over abdomen
5.character Dull aching
6.nature continuous
B.Vomitings 1.number Twice
2.colour Yellowish white
3.character Non projectile
4.quantity 30 ml each time
C.Bowels 1.frequency Once only
2.diarrhea No
3.blood & mucus No
4.malena No
5.haematemesis No
PAST HISTORY
1.History suggesting peptic ulcer Present
2.Duration of symptoms 3 yrs
3.Periodicity Present
4.Pain in relation to food intake Relieved after food intake
5.History of drug ingestion No
6.Associated symptoms
a)vomitings Nil
b)haematemesis Nil
c)malena Nil
7.Any serious previous illness Nil
8.Operation Nil
9.Loss of weight Nil
10.Diabetes mellitus Nil
11.Enteric fever Nil
12.Cardio vascular disease Nil

PERSONAL HISTORY
1.Appetite Normal
2.Diet Mixed diet and spicy
3.Micturition Normal
4.Bowels Regular
5.Sleep Disturbed since 2 days
6.Addictions
a)alcoholism occassionally coutry liqour and toddy since 5 yrs
b)smoking 10-15 cigarettes per day since 10 yrs
c)chewing tobacco yes
FAMILY HISTORY Nil particular
TREATMENT HISTORY Antacids,H2 receptor antagonists

GENERAL EXAMINATION

A.General Appearance Drowsy and in shock


1.Built Well
2.Pallor No
3.Dehydration Severe
4.Eyes Sunken
5.Tongue Dry & pink
6.Teeth Normal
VITAL DATA
1.Pulse 94 min
2.Temparature normal
3.Respiration 26/min
4.B.P. 84/60 mm
B.Abdominal examination
INSPECTION
a)Shape of abdomen grossly distended
b)Movement of abdominal wall with respiration Restricted over upper abdomen
c)Hernia sites Normal
PALPATION
a)Tenderness Diffuse in all quadrants
b)Gaurding Present
c)Muscular rigidity Present
d)Rebound tenderness Present
PERCUSSION
1.Liver dullness Obliterated
2.Shifting dullness present
AUSCULTATION
1.Bowel sounds Absent

SYSTEMIC EXAMINATION
a)Heart Normal
b)Lungs Normal
c)CNS Normal
d)Spine Normal
e)Scrotum Normal
PROVISIONAL DIAGNOSISAcute Duodenal ulcer Perforation with Peritonitis
INVESTIGATIONS
1.Urine
a)Albumin Nil
b)Sugar Nil
2.Hb% 76%
3.Blood urea 25mg
4.Blood sugar 89 mg
5.Blood group AB + ve
6.Plain X-ray abdomen erect posture Free air under domes of Diaphragm
No. 1079 Date 7/3/2008
TREATMENT
1.Preoperative
a)Nothing by mouth
b)Ryel's tube aspiration
c)Intravenous fluids
d)I.V.Antibiotics
e)No enema
2.Anaesthesia General Endo Tracheal
3.Operation text
a)Incision Upper Midline Laporatomy
b)Findings
1.Exudate 7 litres of greenish yellow thick fluid in peritoneal cavity
2.Perforation 1 cm Size on anterior surface of 1 st part of duodenum

PROCEDURE
Simple closure of perforation with 2-0 silk,with omental patch.Peritoneal toilet done
with 2 litres of normal saline,Wound closed in layers after keeping bilateral flank
drains.
POST OPERATIVE PERIODUneventful

NasoGastric aspiration,Antibiotics,IV Fluids

Recovery from paralytic Ileus 48 hrs

COMPLICATIONS UTI treated with Norfloxacin


Post operative fever Absent
Wound infection No
Post operative vomitings No
Suture removal 8 th post op day
Discharged on 13 th post op day
Hospital stay 13 days
Interval between onset of symptoms and surgery 65 hrs
Follow up One year without complications
CASE NO.-7

Name P.Raju DOA 2/4/2008


Age 50 yrs DOO 2/4/2008 6.00pm
Sex Male DOD 20/4/08
ResidenceLaxmipuram,Duggondi(mandal) Result Relieved
Dist.Warangal Regd.No. 11559
Occupation Agriculture
Complaints
1.Pain abdommen since 1 day
2.Unable to pass urine since 1 day

HISTORY OF PRESENT ILLNESS


A.Pain 1.onset Sudden
2.duration Since 26 hrs
3.location First in epigastrium
4.radiation To all over abdomen
5.character Piercing
6.nature Constant incresing in intensity
B.Vomitings 1.number
2.colour
3.character no vomiting
4.quantity
C.Bowels 1.frequency once in two days
2.diarrhea Nil
3.blood & mucus Nil
4.malena Nil
5.haematemesis Nil
PAST HISTORY
1.History suggesting peptic ulcer Present
2.Duration of symptoms 10 yrs
3.Periodicity Present
4.Pain in relation to food intake Relieved after food or soda
5.History of drug ingestion Nil
6.Associated symptoms
a)vomitings Nil
b)haematemesis Nil
c)malena Nil
7.Any serious previous illness Nil
8.Operation Nil
9.Loss of weight Nil
10.Diabetes mellitus Nil
11.Enteric fever Nil
12.Cardio vascular disease Nil

PERSONAL HISTORY
1.Appetite Good
2.Diet Mixed & spicy
3.Micturition Oliguria since 12 hrs
4.Bowels Constipated since 3 days
5.Sleep Normal
6.Addictions
a)alcoholism Toddy 1 litre once a week since 25 yrs
b)smoking 6 cigars daily since 20 yrs
c)chewing tobacco No
FAMILY HISTORY Nil particular
TREATMENT HISTORY
soda ingestion,antacids for 8 yrs
GENERAL EXAMINATION

A.General Appearance Conscious coherent


1.Built Average
2.Pallor No
3.Dehydration Severe
4.Eyes sunken
5.Tongue Dry & pink
6.Teeth Normal
VITAL DATA
1.Pulse 100 min feeble
2.Temparature 98 degree F
3.Respiration 34/min
4.B.P. 70/50
B.Abdominal examination
INSPECTION
a)Shape of abdomen Distended lower abdomen
b)Movement of abdominal wall with respiration Diminished movements
c)Hernia sites Normal
PALPATION
a)Tenderness All over abdomen
b)Gaurding All over abdomen
c)Muscular rigidity in epigastium
d)Rebound tenderness Present
PERCUSSION
1.Liver dullness Obliterated
2.Shifting dullness Present
AUSCULTATION
1.Bowel sounds Absent

SYSTEMIC EXAMINATION
a)Heart Normal
b)Lungs Normal
c)CNS Normal
d)Spine Normal
e)Scrotum Normal
PROVISIONAL DIAGNOSISPeritonoitis due Duodenal ulcer Perforation
INVESTIGATIONS
1.Urine
a)Albumin Nil
b)Sugar Nil
2.Hb% 80%
3.Blood urea 48 mg
4.Blood sugar 98 mg
5.Blood group A +ve
6.Plain X-ray abdomen erect posture free air under diaphragm
No. 6883 Date 2/4/2008
TREATMENT
1.Preoperative
a)Nothing by mouth
b)Ryel's tube aspiration
c)Intravenous fluids
d)I.V.Antibiotics
e)No enema
2.Anaesthesia General Endo Tracheal
3.Operation text
a)Incision Upper Midline Laporatomy
b)Findings
1.Exudate 2 litre of bile stained fluid
2.Perforation 1 cm Size on the anterior wall of 1 st part of duodenum

PROCEDURE
Simple closure of perforation with 2-0 silk,with omental patch.Peritoneal toilet done
with 2 litres of normal saline,Wound closed in layers after keeping bilateral flank
drains.
POST OPERATIVE PERIOD

NasoGastric aspiration,Antibiotics,IV Fluids


One unit of blood transfusion

Recovery from paralytic Ileus 36 hrs


Drains removed 5 th POD
COMPLICATIONS Loose motions 2 nd POD
Post operative fever absent
Wound infection No
Post operative vomitings No
Suture removal 8 th POD
Discharged on 18 th POD
Hospital stay 18 DAYS
Interval between onset of symptoms and surgery 36 hrs
Follow up only once after one month later he did not report
CASE NO.-8

Name Jannu Sambaiah DOA 4/7/2008


Age 50 Yrs DOO 4/7/08 4.30pm
Sex Male DOD 18/7/08
ResidenceHasanparthy ,(mandal) Result Relieved
Dist.Warangal Regd.No. 23039
Occupation Rikshaw puller
Complaints
1.Pain abdomen since 2 hrs

HISTORY OF PRESENT ILLNESS


A.Pain 1.onset Sudden
2.duration since 2hrs
3.location started in epigastrium
4.radiation to Rt.Iliac fossa
5.character bursting & aching
6.nature continuous
B.Vomitings 1.number
2.colour
3.character no vomitings
4.quantity
C.Bowels 1.frequency daily once
2.diarrhea nil
3.blood & mucus nil
4.malena nil
5.haematemesis nil
PAST HISTORY
1.History suggesting peptic ulcer absent
2.Duration of symptoms nil
3.Periodicity nil
4.Pain in relation to food intake nil
5.History of drug ingestion analgesics on & off for back pain
6.Associated symptoms
a)vomitings nil
b)haematemesis nil
c)malena once 8 months back
7.Any serious previous illnessnil
8.Operation nil
9.Loss of weight nil
10.Diabetes mellitus nil
11.Enteric fever nil
12.Cardio vascular disease nil

PERSONAL HISTORY
1.Appetite good
2.Diet Mixed with plenty of chillies
3.Micturition Normal
4.Bowels Regular
5.Sleep Normal
6.Addictions
a)alcoholism Toddy 1 litre a day since 32 yrs
b)smoking smokes 2-3 cigarettes daily
c)chewing tobacco no
FAMILY HISTORY Nil Particular
TREATMENT HISTORY Nil Particular

GENERAL EXAMINATION

A.General Appearance Conscious & coherent


1.Built Thin
2.Pallor No
3.Dehydration Severe
4.Eyes sunken
5.Tongue Dry & Pink
6.Teeth normal
VITAL DATA
1.Pulse 100/min Regular
2.Temparature normal
3.Respiration 22/min
4.B.P. 110/60
B.Abdominal examination
INSPECTION
a)Shape of abdomen Flat
b)Movement of abdominal wall with respiration restricted over upper part of abdomen
c)Hernia sites Normal
PALPATION
a)Tenderness Rt.Hypochondrium &Rt.Iliac fossa
b)Gaurding Rt.Hypochondrium &Rt.Iliac fossa
c)Muscular rigidity Absent
d)Rebound tendernessRt.Iliac fossa
PERCUSSION
1.Liver dullness Obliterated
2.Shifting dullness Present
AUSCULTATION
1.Bowel sounds Absent

SYSTEMIC EXAMINATION
a)Heart Normal
b)Lungs Normal
c)CNS Normal
d)Spine Normal
e)ScrotumNormal
PROVISIONAL DIAGNOSISDuodenal ulcer Perforation
INVESTIGATIONS
1.Urine
a)Albumin2 +
b)Sugar Nil
2.Hb% 80%
3.Blood urea 20 mg
4.Blood sugar 145 mg
5.Blood group O + ve
6.Plain X-ray abdomen erect posture free air under diaphragm
No. 5162 Date 4/7/2008
TREATMENT
1.Preoperative
a)Nothing by mouth
b)Ryel's tube aspiration
c)Intravenous fluids
d)I.V.Antibiotics
e)No enema
2.Anaesthesia General Endo Tracheal
3.Operation text
a)Incision Upper Midline Laporatomy
b)Findings
1.Exudate500 ml of bile stained fluid in peritoneal fluid
2.Perforation 3 mm Size on the anterior wall of 1 st part of Duodenum

PROCEDURE
Simple closure of perforation with 2-0 silk,with omental patch.Peritoneal toilet done
with 2 litres of normal saline,Wound closed in layers after keeping bilateral flank
drains.
POST OPERATIVE PERIOD
Uneventful
NasoGastric aspiration,Antibiotics,IV Fluids

Recovery from paralytic Ileus 48 hrs


Drains removed 4th POD
COMPLICATIONS
Post operative fever Nil
Wound infection Nil
Post operative vomitings Nil
Suture removal 11 th POD
Discharged on 14 th POD
Hospital stay 14 days
Interval between onset of symptoms and surgery nine and half hours
Follow upFor one year was asymptomatic
CASE NO.-9

Name D.Vishnu DOA 11/7/2008


Age 29 Yrs DOO 11/7/2008 8:00 PM
Sex Male DOD 23/7/08
ResidenceBhoopalpally,(mandal) Result Relieved
Dist.Warangal Regd.No. 23985
Occupation
Labourer
Complaints
1.Pain abdomen for 3 days
2.Vomitings for 1 day

HISTORY OF PRESENT ILLNESS


A.Pain 1.onset Sudden
2.duration72 hrs
3.locationFirst in epigastrium
4.radiationto all over abdomen
5.characterPiercing
6.nature Continuous
B.Vomitings 1.number3 times
2.colour greenish white
3.characterMixed with food
4.quantity50-100 ml
C.Bowels 1.frequency
2.diarrhea Nil
3.blood & mucus Nil
4.malena Nil
5.haematemesis Nil
PAST HISTORY
1.History suggesting peptic ulcer Absent
2.Duration of symptoms Nil
3.Periodicity Nil
4.Pain in relation to food intake Nil
5.History of drug ingestion Nil
6.Associated symptoms
a)vomitings Nil
b)haematemesis Nil
c)malena Nil
7.Any serious previous illness Nil
8.Operation Nil
9.Loss of weight Nil
10.Diabetes mellitus Nil
11.Enteric fever Nil
12.Cardio vascular disease Nil

PERSONAL HISTORY
1.Appetite Normal
2.Diet Mixed with plenty of chillies
3.Micturition Normal
4.Bowels constipated
5.Sleep disturbed since 3 days
6.Addictions
a)alcoholism 250 ml Gudumba daily since 5 yrs
b)smoking 5 beedies daily since 9 yrs
c)chewing tobacco no
FAMILY HISTORY nil particular
TREATMENT HISTORY nil particular

GENERAL EXAMINATION

A.General Appearance
1.Built Moderate
2.Pallor Absent
3.Dehydration Severe
4.Eyes Sunken
5.Tongue Dry ,coated
6.Teeth normal
VITAL DATA
1.Pulse 120/min feeble
2.Temparature Normal
3.Respiration 24/min
4.B.P. 90/60
B.Abdominal examination
INSPECTION
a)Shape of abdomen Flat
b)Movement of abdominal wall with respiration restricted
c)Hernia sites Normal
PALPATION
a)Tenderness All over abdomen
b)Gaurding present
c)Muscular rigidity present
d)Rebound tendernessPresent
PERCUSSION
1.Liver dullness Obliterated
2.Shifting dullness Present
AUSCULTATION
1.Bowel sounds Absent

SYSTEMIC EXAMINATION
a)Heart Normal
b)Lungs Normal
c)CNS Normal
d)Spine Normal
e)ScrotumNormal
PROVISIONAL DIAGNOSISAcute Perforation of Duodenal ulcer with Peritonitis
INVESTIGATIONS
1.Urine
albumin 2+
b)Sugar Nil
2.Hb% 70%
3.Blood urea 40 mg
4.Blood sugar 78 mg
5.Blood group O +ve
6.Plain X-ray abdomen erect posture free air under diaphragm
No. 3161 Date 10/7/2008
TREATMENT
1.Preoperative
a)Nothing by mouth
b)Ryel's tube aspiration
c)Intravenous fluids
d)I.V.Antibiotics
e)No enema
2.Anaesthesia General Endo Tracheal
3.Operation text
a)Incision Upper Midline Laporatomy
b)Findings
1.Exudate3 litres straw colored fluid
2.Perforation 3 mm Size round shaped on anterior surface of 1 st part of
Duodenum
PROCEDURE
Simple closure of perforation with 2-0 silk,with omental patch.Peritoneal toilet done
with 2 litres of normal saline,Wound closed in layers after keeping bilateral flank
drains.

POST OPERATIVE PERIOD


Uneventful
NasoGastric aspiration,Antibiotics,IV Fluids

Recovery from paralytic Ileus 48 hrs


Drains removed 5th POD
COMPLICATIONS
Post operative fever on 5 th POD treated with antipyretic
Wound infection Nil
Post operative vomitings Nil
Suture removal on 10th POD
Discharged on 12 th POD
Hospital stay 12 days
Interval between onset of symptoms and surgery 72 hrs
Follow upRepoted only once after one month
CASE NO.-10

Name Vanaparthi Rajaiah DOA 7/8/2008


Age 50 DOO 7/8/2008 9.30 pm
Sex Male DOD 30/8/08
Residencepothakapally,Odela(mandal) Result Relieved
Dist.Karimnagar Regd.No. 27987
Occupation Toddy Tapper
Complaints
1.Distension of abdomen since 3 days
2.Passing small quantities of urine 3 days

HISTORY OF PRESENT ILLNESS


A.Pain 1.onset sudden
2.duration3days
3.locationfirst in epigastrium
4.radiationto all over the abdomen
5.characterdragging
6.nature continuous
B.Vomitings 1.number
2.colour
3.character no vomitings
4.quantity
C.Bowels 1.frequency once daily
2.diarrhea Nil
3.blood & mucus Nil
4.malena Nil
5.haematemesis Nil
PAST HISTORY
1.History suggesting peptic ulcer Present
2.Duration of symptoms 8 yrs
3.Periodicity Present
4.Pain in relation to food intake relieved after food
5.History of drug ingestion Nil
6.Associated symptoms
a)vomitings Nil
b)haematemesis Nil
c)malena Nil
7.Any serious previous illness Nil
8.Operation Nil
9.Loss of weight Nil
10.Diabetes mellitus Nil
11.Enteric fever Nil
12.Cardio vascular disease Nil

PERSONAL HISTORY
1.Appetite Normal
2.Diet Mixed with chillies
3.Micturition Normal
4.Bowels Normal
5.Sleep disturbed due to pain
6.Addictions
a)alcoholism 250 ml gudumba daily for 31 yrs
b)smoking 2-3 cigars 32 yrs
c)chewing tobacco no
FAMILY HISTORY Nil particular
TREATMENT HISTORY Irregular use of antacids

GENERAL EXAMINATION

A.General Appearance
1.Built Thin
2.Pallor absent
3.Dehydration present
4.Eyes sunken
5.Tongue dry pink
6.Teeth Normal
VITAL DATA
1.Pulse 100/min,low vol.
2.Temparature Normal
3.Respiration 20/min
4.B.P. 120/80
B.Abdominal examination
INSPECTION
a)Shape of abdomen Distended
b)Movement of abdominal wall with respiration restricted in upper abdomen
c)Hernia sites Normal
PALPATION
a)Tenderness Diffuse
b)Gaurding Rt.Hypochondrium,epigastrium,Rt.iliac fossa
c)Muscular rigidity Rt.Hypochondrium,epigastrium,Rt.iliac fossa
d)Rebound tenderness Present
PERCUSSION
1.Liver dullness Obliterated
2.Shifting dullness Present
AUSCULTATION
1.Bowel sounds Sluggish

SYSTEMIC EXAMINATION
a)Heart Normal
b)Lungs Normal
c)CNS Normal
d)Spine Normal
e)ScrotumNormal
PROVISIONAL DIAGNOSISAcute Perforation of Duodenal ulcer with Peritonitis
INVESTIGATIONS
1.Urine
a)Albumin
b)Sugar
2.Hb%
3.Blood urea
4.Blood sugar
5.Blood group
6.Plain X-ray abdomen erect posture free air under diaphragm
No. 5765 Date 7/8/2008
TREATMENT
1.Preoperative
a)Nothing by mouth
b)Ryel's tube aspiration
c)Intravenous fluids
d)I.V.Antibiotics
e)No enema
2.Anaesthesia General Endo Tracheal
3.Operation text
a)Incision Upper Midline Laporatomy
b)Findings
1.Exudate4 litres of yellowish green fluid present
2.Perforation 1 cm Size on anterior surface of 1 st part of Duodenum

PROCEDURE
Simple closure of perforation with 2-0 silk,with omental patch.Peritoneal toilet done
with 2 litres of normal saline,Wound closed in layers after keeping bilateral flank
drains.

POST OPERATIVE PERIOD


Uneventful
NasoGastric aspiration,Antibiotics,IV Fluids

Recovery from paralytic Ileus 72 hrs


Drains removed 5th POD
COMPLICATIONS
Post operative fever present treated with anti pyretic
Wound infection Present
Post operative vomitings Nil
Suture removal 10 th POD
Discharged on 25 th POD
Hospital stay 25Days
Interval between onset of symptoms and surgery 80 hrs
Follow upFollowed up for 6 months asymptomatic,subsequently did not report for follow up
CASE NO.-11

Name Marepally Ilaiah DOA 10/8/2008


Age 50 yrs DOO 10/8/2008 3.15 pm
Sex Male DOD 19/8/08
ResidenceShyampet,(mandal) Result Relieved
Dist.Warangal Regd.No. 28288
Occupation Agriculture
Complaints
1.Pain abdomen for 1 day
2.Fever since one day
3.Not passing motion since the day before morning

HISTORY OF PRESENT ILLNESS


A.Pain 1.onset Sudden
2.duration 24 hrs
3.location first in epigastium
4.radiation to Rt.Iliac fossa
5.character Piercing
6.nature continuous increasing in severity
B.Vomitings 1.number
2.colour
3.character no vomiting
4.quantity
C.Bowels 1.frequency daily once
2.diarrhea Nil
3.blood & mucus Nil
4.malena Nil
5.haematemesis Nil
PAST HISTORY
1.History suggesting peptic ulcer Present
2.Duration of symptoms 4 yrs
3.Periodicity Present
4.Pain in relation to food intake relieved after food
5.History of drug ingestion Taking Aspirin frequently for body pains
6.Associated symptoms
a)vomitings Nil
b)haematemesis Nil
c)malena once one month back
7.Any serious previous illnessNil
8.Operation Nil
9.Loss of weight Nil
10.Diabetes mellitus Nil
11.Enteric fever Nil
12.Cardio vascular disease Nil

PERSONAL HISTORY
1.Appetite good
2.Diet Mixed spicy food
3.Micturition Normal
4.Bowels Normal
5.Sleep disturbed due to pain
6.Addictions
a)alcoholism 200 ml of Gudumba since 25 yrs
b)smoking 10 beedies daily since 32 yrs
c)chewing tobacco occassionally
FAMILY HISTORY Nil particular
TREATMENT HISTORY irregular use of antacids

GENERAL EXAMINATION

A.General Appearance
1.Built Moderate
2.Pallor No
3.Dehydration Severe
4.Eyes sunken
5.Tongue dry pink
6.Teeth Normal
VITAL DATA
1.Pulse 102 /min Regular
2.Temparature Normal
3.Respiration 24 /min
4.B.P. 110/80 mmHg
B.Abdominal examination
INSPECTION
a)Shape of abdomen Flat
b)Movement of abdominal wall with respiration Diminished in upper part
c)Hernia sites Normal
PALPATION
a)Tenderness Diffuse
b)Gaurding Rt.hypochondrium,epigastrium
c)Muscular rigidity Absent
d)Rebound tenderness Rt.iliac fossa
PERCUSSION
1.Liver dullness Obliterated
2.Shifting dullness Present
AUSCULTATION
1.Bowel sounds Present
SYSTEMIC EXAMINATION
a)Heart Normal
b)Lungs Normal
c)CNS Normal
d)Spine Normal
e)ScrotumNormal

PROVISIONAL DIAGNOSIS Acute Perforation of Duodenal ulcer with Peritonitis


INVESTIGATIONS
1.Urine
a)Albumintrace
b)Sugar nil
2.Hb% 76%
3.Blood urea 50 mg
4.Blood sugar 68 mg
5.Blood group O +ve
6.Plain X-ray abdomen erect posture free air under diaphragm
No. 3679 Date 10/8/2008
TREATMENT
1.Preoperative
a)Nothing by mouth
b)Ryel's tube aspiration
c)Intravenous fluids
d)I.V.Antibiotics
e)No enema
2.Anaesthesia General Endo Tracheal
3.Operation text
a)Incision Upper Midline Laporatomy
b)Findings
1.Exudate300 ml of purulent fluid in peritoneum
2.Perforation 3 mm Size round shaped anterior aspect of 1 st part of Duodenum

PROCEDURE
Simple closure of perforation with 2-0 silk,with omental patch.Peritoneal toilet done
with 2 litres of normal saline,Wound closed in layers after keeping bilateral flank
drains.

POST OPERATIVE PERIOD


Uneventful
NasoGastric aspiration,Antibiotics,IV Fluids

Recovery from paralytic Ileus 48 hrs


Drains removed 5th POD
COMPLICATIONS
Post operative feverAbsent
Wound infection No
Post operative vomitings No
Suture removal 7 th POD
Discharged on 10 th POD
Hospital stay 10 days
Interval between onset of symptoms and surgery 36 hrs
Follow up One yr follow up with PPI'S asymptomatic
CASE NO.-12

Name T.Komraiah DOA 16/12/08


Age 48 yrs DOO 16/12/08 7.30 pm
Sex Male DOD 25/12/08
ResidenceIppagudem,St.Ghanpure(mandal) Result Relieved
dist.Warangal Regd.No. 47881
Occupation
Agriculture
Complaints
1.Pain abdomen since 48 hrs
2.Not passing stools for 2 days

HISTORY OF PRESENT ILLNESS


A.Pain 1.onset Sudden
2.duration48 hrs
3.locationFirst In epigasrium
4.radiationto all over abdomen
5.character dragging
6.nature continuous,increasing in severity
B.Vomitings 1.number
2.colour
3.character no vomiting
4.quantity
C.Bowels 1.frequency constipated for 2 days
2.diarrhea Nil
3.blood & mucus Nil
4.malena Nil
5.haematemesis once 5 ml
PAST HISTORY
1.History suggesting peptic ulcer Present
2.Duration of symptoms 2 yrs
3.Periodicity Present
4.Pain in relation to food intake relieved after food
5.History of drug ingestion Nil
6.Associated symptoms
a)vomitings Nil
b)haematemesis Nil
c)malena Nil
7.Any serious previous illness Nil
8.Operation Nil
9.Loss of weight Nil
10.Diabetes mellitus Nil
11.Enteric fever Nil
12.Cardio vascular disease Nil

PERSONAL HISTORY
1.Appetite Normal
2.Diet Mixed lot of chillies
3.Micturition Normal
4.Bowels constipated
5.Sleep disturbed during pain
6.Addictions
a)alcoholism Gudumba 250 ml -500 ml daily for 8 yrs
b)smoking 2-3 cigars for 28 yrs
c)chewing tobacco No
FAMILY HISTORY Nil particular
TREATMENT HISTORY Nil particular

GENERAL EXAMINATION

A.General Appearance
1.Built Moderate
2.Pallor No
3.Dehydration Present
4.Eyes Sunken
5.Tongue Dry pink
6.Teeth Normal
VITAL DATA
1.Pulse 80 /min regular
2.Temparature Normal
3.Respiration 34 /min
4.B.P. 140/90 mmHg
B.Abdominal examination
INSPECTION
a)Shape of abdomen Distended
b)Movement of abdominal wall with respiration restricted in upper abdomen
c)Hernia sites Normal
PALPATION
a)Tenderness Diffuse
b)Gaurding Rt.hypochondrium
c)Muscular rigidity Present
d)Rebound tenderness Present
PERCUSSION
1.Liver dullness Obliterated
2.Shifting dullness Present
AUSCULTATION
1.Bowel sounds Sluggish

SYSTEMIC EXAMINATION
a)Heart Normal
b)Lungs Normal
c)CNS Normal
d)Spine Normal
e)ScrotumNormal
PROVISIONAL DIAGNOSISAcute Perforation of Duodenal ulcer with Peritonitis
INVESTIGATIONS
1.Urine
a)Albuminnil
b)Sugar nil
2.Hb% 70%
3.Blood urea 30 mg
4.Blood sugar 100 mg
5.Blood group B +ve
6.Plain X-ray abdomen erect posture free air under diaphragm
No. 7327 Date 16/12/08
TREATMENT
1.Preoperative
a)Nothing by mouth
b)Ryel's tube aspiration
c)Intravenous fluids
d)I.V.Antibiotics
e)No enema
2.Anaesthesia General Endo Tracheal
3.Operation text
a)Incision Upper Midline Laporatomy
b)Findings
1.Exudate4 litres of greenish brown moderately turbid ,fibrinous flakes over intestines
2.Perforation 4 mm Size,circular shape anterior aspect 1st part of duodenum

PROCEDURE
Simple closure of perforation with 2-0 silk,with omental patch.Peritoneal toilet done
with 2 litres of normal saline,Wound closed in layers after keeping bilateral flank
drains.

POST OPERATIVE PERIOD


Uneventful
NasoGastric aspiration,Antibiotics,IV Fluids

Recovery from paralytic Ileus48 hrs


Drains removed 5th POD
COMPLICATIONS
Post operative fever Absent
Wound infection No
Post operative vomitings No
Suture removal 9 th POD
Discharged on 9 th POD
Hospital stay 9 days
Interval between onset of symptoms and surgery60 hrs
Follow up For one yr,asymptomatic