perforasi gaster
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Perforasi GasterTRANSCRIPT
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EMERGENCY CASE REPORTS
Sunday, November 15th, 2010
SURGERY DEPARTMENT
EMERGENCY ROOMEMERGENCY ROOMWAHIDIN WAHIDIN
SUDIROHUSODO SUDIROHUSODO GENERAL HOSPITALGENERAL HOSPITAL
MAKASSARMAKASSAR
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Sunday, November 15th 2010
AmbulationAmbulation :: 22 PatientsPatients
Hospitalized Hospitalized :: 44 patientspatients
ObservationObservation :: 11 PatientPatient
OperatedOperated :: 33 PatientsPatients
DeathDeath :: PatientPatient
TotalTotal :: 88 patientspatients
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No. 5Name : Mr. A Sex : MaleAge : 79 years old No. Reg : 44 79 33
Chief complaint : Pain at the whole abdomen wallHistory taking : Suffered since 2 days before admitted to the
hospital. At the first, patient complained of sudden abdominal pain at the center of abdomen. The pain become worse and followed by bloating, nausea and vomiting. And then he felt pain at the whole abdomen and got fever. He was brought to primary health care and referred to Wahidin Hospital .
Defecation : Never defecation and flatus since 2 days agoMicturation : Less than normal.
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Physical Examination
General Conditions
: Severe illness/ well nourished / conscious
Vital sign : BP : 140/90 mmHgPR : 120 x/ minutes RR : 22 x/ minutesT : 38,5° C
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AbdomenAbdomen
I : Distended, follow of breath motion, no , no bowel contour, no bowel movements, no tumor mass.
A : Bowel sound (+), decreasedP : Tympani (+), Tapping pain (+)
P : Tenderness (+), Defans muscular (+)
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Rectal Toucher
Sphincter ani was loose. Mucous was smooth. Ampula was empty. No palpable tumor mass.
Gloves : feces (-), blood (-), slime (-)
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Laboratory Result Laboratory Result WBC : 13, 53 x 103 / μL Natrium : 146 mmol/l
RBC : 4.73 x 106 / μL Kalium : 4, 4 mmol/l
HGB : 13,7 g/dL Chloride : 102 mmol/l
HCT : 40,0 % HBsAg : Negatif
PLT : 299 x 103 / μL Anti HCV : Negatif
CT / BT : 7’00” / 3’00” Uric acid : 9, 7
Blood Sugar : 119 mg/dl Albumin : 2, 6
Ureum : 143 mg/dl
Creatinin : 3, 1 mg/dl
SGOT/SGPT : 104/111 u/l
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Thorax AP X-Ray
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Abdominal X-Ray Supine Position
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Abdominal X-Ray Erect Position
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WORKING DIAGNOSIS : Peritonitis generalisata et causa suspect perforation gaster.
MANAGEMENT : O2 IVFD Resuscitation apply NGT and urine catheter Medicamentous Report to senior digestive surgeon : Advice : immediately laparatomy exploration
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Operating Procedure• Patient laid supine under epidural and GA• Desinfection & drapping Procedure• Midline incision 2 fingers under Proc. Xyphoideus until 3 fingers upper
SOP• Open peritoneum Identification solid organ seen no abnormallities• Continued with hollow viscous exploration seen anthrum perforation size
1 x 1,5 cm• Stiched perforation with primary suture continued with omental flap• Perform NGT no.18 at gaster and 12 for nutrition at duodenum• Wash peritoneal cavity with normal saline.• Stitch the wound layer by layer and leaving 1 drain• Operation finished
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POST OPERATIVE DIAGNOSIS
: Peritonitis generalisata et causa antrum gastric perforation
PROGNOSIS
FOLLOW UP
:
:
Good
Vital Sign