No.

Name : Ms. AY Sex : Female

Age : 27 years No. Reg : 627258

Chief complaint : Abdominal Pain

History taking : The condition had been apparent since 1 week. The
pain localized especialy on right side of abdomen.
There is no refered pain to other side. The patient
had fever for 4 weeks.
Defecation : Normal
Micturated : Normal
 Physical Examination

General Conditions:
Moderate illness / well nourish / conscious

Vital sign:
BP : 140/60 mmHg
PR : 112 x/mnt, regular, adequate.
RR : 36 x/mnt.
T(Ax) : 36,8 C
PHYSICAL EXAMINATION
Abdomen
I : Seen flat, follow breath motion, no bowel contour, no bowel motion.

A : Decreased of Bowel sound

P : Tenderness at whole abdomen ,Muscular defans (+)

P : Tympani
Rectal Toucher

Sphincter ani was loose,

Mucous was smooth,
Ampula collapse
No palpable mass,
No pain at palpation

Gloves : Faeces (-), blood (-), slime (-)

 Laboratory Result
WBC : 8.3 x 103 / L Na : 140

RBC : 3.49 x 106 / L K : 3,3

HGB : 10.1 g/dL Cl : 105

HCT : 29.6 %

PLT : 434x 103 / L

CT / BT : 700 / 300

Blood Sugar : 100 mg/dl

Ureum : 56 mg/dl

Creatinin : 1, 0mg/dl

SGOT/SGPT : 104/59 u/l

Thorax X-Ray
BNO X-Ray
WORKING DIAGNOSIS : Generalize Peritonitis e.c Hollow Viscus Perforation

MANAGEMENT : IVFD
Apply NGT
Apply Foley Catheter urine
Medicaments
Report to Senior Digestive Surgeon
advice :
 OPERATION PROCEDURE
Patient laid supine under GA
Disinfection and drapping procedure
Performed midline incision 2 fingers below
proc.xyphoideus until 3 3 fingers above simphisis pubis
Deepen until peritoneum, seen intestinal adhesion
Perrform exploration, found perforation at antrum of th
Primer suture then perform omental flap
Control the bleeding and rinse cavum abdomen
Close wound layer by layer with 1 drain
Done
POST OP DIAGNOSIS : Ileus obstructive due to rectosigmoid tumour

PROGNOSIS : Good

FOLLOW UP : Vital Sign

Abdominal Pain
No.
Name : Ms. AY Sex : Female
Age : 27 years No. Reg : 627258

Chief complaint : Headache

History taking : The condition had been apparent since 1 week. The
pain localized especialy on right side of abdomen.
There is no refered pain to other side. The patient
had fever for 4 weeks.
Defecation : Normal
Micturated : Normal
PHYSICAL EXAMINATION
Primary Survey
A: Clear

B: RR: 20x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP: 100/80 mmHg, PR: 72 x/minute, regular, adequate

D: GCS 15 (E4M6V5), pupil equal 2,5mm / 2,5mm, Light

Reflex +/+
E: T (ax): 36,9 oC
Secondary Survey

Left Frontotemporal Region

I: Seen already stiched wound size 0,2x6 cm,
edema (-) hematoma (-), active bleeding (-)
P: Tenderness difficult to evaluated , crepitating (-)
Right Forearm Region
I: Seen already steached wound size 0,2x6 cm,
edema (-) hematoma (-), active bleeding (-)
P: Tenderness difficult to evaluated , crepitating (-)
No. 1
Name : Mr.ARS Sex : Male
Age : 47 years old No. Reg : 604129

Main complaint : Puncture wound at right foot

History taking : Sufferred about 2 hours prior to admission to hospital.

mechanism of : He was cleaning house and sudenly he tread or step

injury onwhen accidently step on abandoned rusty nail.

Sustained Injury : Right foot

Symptom & sign : Pain and wound
Examination : Physical examination
Done
PHYSICAL EXAMINATION
Primary Survey
A: Clear

B: RR: 20x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP: 100/80 mmHg, PR: 72 x/minute, regular, adequate

D: GCS 15 (E4M6V5), pupil equal 2,5mm / 2,5mm, Light

Reflex +/+
E: T (ax): 36,9 oC
Secondary Survey
Left plantar pedis region:
I : seen punctured wound size 0,5x0,5
cm, hematoma (-), edema(+)
P : tenderness (+), crepitating (-)
WORKING DIAGNOSIS : Vulnus punctum regio plantar pedis dextra

MANAGEMENT : Medicaments
Cross incision patient discharge