EMERGENCY CASE REPORTS

Tuesday, February 12th 2019

SURGERY DEPARTMENT

EMERGENCY ROOM
Wahidin Sudirohusodo General Hospital
Makassar
EMERGENCY CASE REPORT
Tuesday, February 11th 2019
Ambulation : - Patient
Hospitalized : 9 Patients
Observation : - Patient
Operated : 1 Patient
Death : - Patient
Total : 10 Patients
Wahidin Sudirohusodo General Hospital
Makassar
 Name : Mr. MA Age : 18 y.o
RM : 873273 DPJP : dr. WS

Chief complain : Pain in the all of abdominal wall

History taking : The condition had been apparent 1 day ago And the pain
feel more intens before admitted to the hospital. Initially he
felt pain at epigastric region 3 days ago then move and
settled at right lower quadrant of abdomen and then
spread to the all of abdominal region. There were history
of nausea and vomiting. There was History of Fever, Last
defecation 1 days ago, with the consistency like liquid and
the color was yellow. Prior Medical Care Pinrang Hospital.
Micturation : 1cc/BW/Hour
GENERAL STATUS
Moderate illness / well nourish / conscious / Karnofsky 70%

VITAL SIGN
BP : 120/80 mmHg
PR : 112 x/mnt, strong, reguler,
RR : 25 x/mnt, symmetric L=R, thoracoabdominal
type.
T(Ax) : 37,2°C
 Local Status
Abdominal
I : Flat, follow breath motion, skin color is the same with its vicinity,
darm contour (-), darm steifung (-)
A : Peristaltic (+), sound decreased
P : Muscular defans (+), Tenderness (+)
P : Tympani
 Digital Rectal Examination

Sphincter tone was tight

Mucous was smooth
Ampulla was empty

Handscoon: blood (-), slime (-), feces (+)

 Clinical diagnosis
• Generalized Peritonitis Suspect Perforated
Appendicitis
Abdominal USG
 Laboratory Result
WBC : 13,4 x 103 /μL Natrium : 135 mmol/L

RBC : 5,22, x 106 /μL Kalium : 3,5 mmol/L

HGB : 14,9 g/dL Chlorida : 97 mmol/L

HCT : 41 %

PLT : 167 x103/ Μl

PT/ aPTT : 12,3 s / 32 s

Blood Sugar : 137 mg/dl

Ureum : 32 mg/dl

Creatinin : 0,92 mg/dl

GOT / GPT : 32/18 μ/L

DIAGNOSIS : Generalized Peritonitis e.c Perforated Appendicitis

MANAGEMENT : • IVFD Nacl 0,9%

• Apply Naso Gastric Tube
• Apply Urine Catheter
• Medicaments
• Consult Digestive Surgeon : Immediate Laparatomy
Exploration with Appendectomy
Thank You