MORNING

CONFERENCE

R/Male/23 yo

19 October 2017
Chief complaint: Pain on the whole abdomen
It has been suffered by the patient since 3 days ago. Initially the
symptom was started on epigastrium and right lower abdomen
since 2 days ago then spreading to whole area of abdomen after
the patient got massages in the abdomen. It followed by nausea
and vomiting (+) more than 2 times a day, history of fever (+) since
3 days ago. Micturition (+) within normal limit. Defecation (+)
within normal limit.
HOD : (-).
HOM : (-)
Present State :
• Awareness : Alert
• BP : 120/80 mmHg
• HR : 88 x/minute
• RR : 22 x/minute
• Temp : 380 C
• VAS :6
Generalized State
• Head and neck : No abnormality was found
• Chest : No abnormality was found
• Abdomen : In localized state
• Extremities : No abnormality was found
• Genitalia : Male, No abnormality was found
Localized state :
Abdomen
I : Symmetric, distention (-)
P : Defans muscular (+),Tenderness (+)
P : Tymphani (+)
A : Peristaltic (+) increase
Digital rectal Examination:
Perineum usual, tight anal sphincter tone,
slippery mucosa, pain (-), ampulla recti filled
faeces, gloves : feces (+), blood (-), mucous (+)
Laboratory findings:

• Hb / RBC /Hct / WBC / PLT : 14.5/ 5.10/ 44.0/18.20/184000

• Netrofil : 88.6
• Na/K/Cl :146/3.70/110
• Ur/Cr :42/1.50
• Random Glucose Level : 126
 Chest X-Ray
• Thorax Erect
Working Diagnose:
• Diffuse Peritonitis d/t susp appendicitis
perforation
Management:
- Fasting
- Insertion catheter (cameout yellow clear urine 100cc)
- IVFD Crystalloid
- Inj. Antibiotic
- Inj. Analgetic
- Patient prepared for Laparotomy Appendectomy in
Emergency Room
Durante Operation