A.W.S General HospitalSAMARINDACASEREPORT Tuesday, March 09th 2015

Team in chargeER :MANWard : NICOK : YRM

Adm. Date : Name:Ny. HSex:FemaleAge:31 yoMR:

Chief complain:Pain at right Upper abdomenHystory taking:Pain at right upper abdomen suffered since 4 month before admitted to Hospital, the pain felt sharp and radiating to the back of the right shoulder. Initially the pain felt seldomly but on last week the pain felt more often. Fever (+), Nausea (+), Vomiting (-). Urine color changed into tea like color, Feces color is pale.Examination:Physical examination, Laboratory examination, Radiology Exam

Physical Examination

Anemic -/- Icteric -/-Thorax : Within normal limitAbdomen : Distended (-)Tenderness (+) at RUQ, Murphy Sign (+), Hepatomegaly (+),TympanicBowel Sound (N)Flank : Flank pain -/-, Flank mass -/-, CVA tenderness -/-, Bulging bladder (-), Genitalia normal

Radiologic Examination

LABORATORY RESULT

Complete Blood CountWBC:20,2 x 103 / LRBC:4,79 x 106 / LHGB:13,9 g/dLHCT:31,7 %PLT:223 x 103 / LBT / CT:200 / 900Blood Sugar:95 mg/dlUreum:23 mg/dlCreatinin:0,9 mg/dl

LABORATORY RESULT

Complete Urination CountBJ:1.015Ketone:-Nitrit:-Leuko:-Hb/blood:-Color:YellowPurity:CloudypH:6,5Protein:+1Glucose:-Billirubin:-Urobilinogen:+

Epithel:+Leuco:1-2Erytro:2-3Silinder:-Crystal:-Bacteria:-Fungi:-

WORKING DIAGNOSIS :Diffuse Peritonitis suspect perforated appendicitis

MANAGEMENT:IVFD RL 2000cc/24 hours Apply NGTApply Urethral catheterInj. Ceftriaxone 1 gr / 12 hourInj. Ranitidin 50mg / 12 hoursEmergency Laparotomy exploration

Co/ general surgeonAgree with treatment