A case of J.D.

15 years old
Male
Catholic
Dalaguete, Cebu
 HPI:
2 days PTA patient had onset of abdominal pain,
gnawing in character with PS of 8/10. Pain radiated
to epigastric area. No associated vomiting and fever.
1 day PTA, abdominal pain persisted with associated
vomiting, no associated fever. No medications taken.
Anorexia also noted. Patient sought consult at
cardinal Rosales Hospital and advised referral at
VSMMC for further management.

Previous surgery: 2001 direct inguinal hernia

 Pertinent PE:

Abdomen: transverse abdominal incision

noted, flat, normoactive bowel sound, + direct
tenderness
 S> Patient complains of pain at incision site with a
painscale of 4/10. (-) bowel movement (-) flatus
O> examined a conscious, coherent ambulatory
patient not in respiratory distress with the
following v/s:
T- 36.8c
P-85bpm
RR-18cpm
BP-120/80mmhg
NGT open to drain at Left nostril
FBC attached to urobag
 skin is warm to touch with good turgor
anicteric sclera, pink palpebral conjunctiva
Neck is supple, (-) LAD
Thorax is symmetric with good expansion,
Clear breath sounds
Distinct heart sound, no murmur
Abdomen is flat, (+) midline incision with
clean dry dressing, hypoactive bowel sounds,
(-) tenderness upon palpation
Good range of motion on all extremities
Latest CBC result: 6/26/2016 11:57pm

Wbc- 7.22
Hgb- 141g/L
Hct- 0.41L/L
Platelet- 272
 Latest ABG result 6/26/2016 10:12pm

Temp-36.9
pH- 7.427
pCo2- 39.7 mmhg
Beecf- 1.7 mmol/L
HCO3- 26.2 mmol/L
TCO2- 27.5 mmol/L
SO2- 97.8 %
 A> Day 2 post op, S/P Exploratory Laparotomy,
adhesiolysis, segmental jejunal resection, with
end to end anastomosis, Lavage, Patient is
stable
P> Monitor V/S q hour, I&O q hour
maintain NPO
Check abdominal Status q shift
Medications:
Piperacillin Tazobactam 2 gms IVTT q 8hrs
Metronidazole 400mg IVTT q 8hrs
Ranitidine 40mg IVTT q 8hrs
Tramadol 40 mg IVTT q 8hrs
>Give paracetamol 300mg IVTT if T>38c
Advise ambulation
Daily Wound Care