Patient Identity

Name

: Zainuddin Enha

Age

Sex

Address

MR

: 1-09-42-75

Phone

: 081315208481

Admission time

Time Response

: 64 years old
: Male
: Ds Tangah Kec Susoh Kab Abdya

Date/h
our
patient
came
to ER

Examina
tion hour

June
22nd
2016

06:50

: 06.45

Laboratory
Examination

Radiology
Examination

Send

Result

Send

Result

07.00

08.40

07.15

08.00

06:45

Hour of
Diagnos
tics

Date/h
our
patient
out
from
ER

DPJP

09.00

10.00

Dr.
Ferry
Erdani
Sp.B
(K) BD

sent to
operatio
n room

Chief Complain:
Pain at the whole abdominal region
Present illness history
The patient was referred from Tengku pekan district hospital to emergency room
with Pain at the whole abdominal region for 1 day,initially patient feel pain at
epigatric area and then spread to whole abdominal region, the patient has history
consumed traditional medicine for 3 years, history of nausea and vomiting (-).

Physical examination
Vital Sign

Blood Presure

: 130 / 85 mmHg

Pulse

: 97 beats / minute

Respiratory rates

: 18 breaths /minute

Temperature

: 37,6 oC

Localize state :
Abdominal

Inspection

Symmetrical, distension (+), darm contour(-)

darm steifung (-)

Auscultation

Bowel sound (+) decrease

Palpation

Defans Muscular (+), pain at the whole

abdominal region

Percussion

Liver dullness (-)

Digital rectal examination

Loose sphincter ani

Empty ampula recti

Smooth mucosa

At glove : faeces (-) blood (-)

Vas : 5

Assessment
General peritonitis due to susp gastric perforation

Management

Stop oral intake

NGT decompression

Oxygen 4 l/minute (nasal canule)

IVFD RL 30 gtt / minute

Inj ceftriaxone 1 g

Inj. Omeprazole 40 mg

Metronidazole drip 500 mg

Drip paracetamol 1000 mg

Urine Catheter initial 60 cc

Laboratory examination

Radiology examination

Laboratory examination :

Hemoglobin

: 11,8 gr/dl

WBC

: 25.600 /ul

Platelet

: 338 x 103/ul

CT/BT

: 7/2

HT

: 35 %

Ureum

Creatinin

Glocouse ad randome

: 99 mg/dl

Sodium

: 140 mmol/L

Potassium

: 3,9 mmol/L

Chloride

: 107 mmol/L

Thorax erect :

: 47 mg/dl
: 1,5 mg/dl

Free air at the right subdiafragma

Diagnose
General peritonitis due to Gastric perforation
Consult to digestive surgery division : Laparotomi Exploration Emergency

Operative report

Midline incision found serous purulent 50 cc

Found perforation at the antrum gastric with diameter 1x0.5 cm

Refreshing perforation border biopsy sent to PA

Perfomed primary sutured with omental patch

Performed 2 drainage

Diagnose post operative:

General peritonitis due to gastric perforation (ICD 10 CM K65.0)

Follow Up

Date

June 24th

Pain
(+)

General condition:
moderate

Post laparotomy
exploration +
omental patch +
biopsy

IVFD RL 20
drip/minute

NGT

due to

Inj ceftriaxone
1 g/12 hour

Metronidazole
500mg/8 hour

Omeprazole
80mg /24hour

Drip
Paracetamol 1
fls /8 hour

Wound care

2016
POD 3

Blood Presure: 140/80

mmHg
HR: 90 beats/minute
RR: 20 beats/minute
S/L abdomen
I : Symmetrical,gauze dry
A: bowel sound (+)

General
peritonitis due to
gastric
perforation ICD
10 (CM K65.0)

P : Pain (+)
P : Liver dullness (+)
Right Drainage :
hemorogic serous

cc

Left Drainage :
hemoragic serous

cc