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    Morpot 13092014

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    Lodewyk Kefas Joshoa
    A 14-year-old boy presented to the emergency room with nausea, vomiting, abdominal pain, fever, and loss of appetite. He had undergone an appendectomy and laparotomy surgery approximately one month ago. On examination, he had tenderness and percussion pain in his abdomen. Laboratory tests showed increased white blood cell count and mildly abnormal liver enzymes. Abdominal x-rays found partial small bowel obstruction, likely due to an intra-abdominal abscess from his previous surgery. He was admitted to the hospital for intravenous antibiotics and monitoring.

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    Morpot 13092014

    Uploaded by

    Lodewyk Kefas Joshoa
    21 views15 pages
    A 14-year-old boy presented to the emergency room with nausea, vomiting, abdominal pain, fever, and loss of appetite. He had undergone an appendectomy and laparotomy surgery approximately one month ago. On examination, he had tenderness and percussion pain in his abdomen. Laboratory tests showed increased white blood cell count and mildly abnormal liver enzymes. Abdominal x-rays found partial small bowel obstruction, likely due to an intra-abdominal abscess from his previous surgery. He was admitted to the hospital for intravenous antibiotics and monitoring.

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    MORPOT 13092014

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    A 14-year-old boy presented to the emergency room with nausea, vomiting, abdominal pain, fever, and loss of appetite. He had undergone an appendectomy and laparotomy surgery approximately one month ago. On examination, he had tenderness and percussion pain in his abdomen. Laboratory tests showed increased white blood cell count and mildly abnormal liver enzymes. Abdominal x-rays found partial small bowel obstruction, likely due to an intra-abdominal abscess from his previous surgery. He was admitted to the hospital for intravenous antibiotics and monitoring.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    21 views15 pages

    Morpot 13092014

    Uploaded by

    Lodewyk Kefas Joshoa
    A 14-year-old boy presented to the emergency room with nausea, vomiting, abdominal pain, fever, and loss of appetite. He had undergone an appendectomy and laparotomy surgery approximately one month ago. On examination, he had tenderness and percussion pain in his abdomen. Laboratory tests showed increased white blood cell count and mildly abnormal liver enzymes. Abdominal x-rays found partial small bowel obstruction, likely due to an intra-abdominal abscess from his previous surgery. He was admitted to the hospital for intravenous antibiotics and monitoring.

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    You are on page 1of 15

    1. Boy.

    Z
    (14 YO)
    62.82.05.00








    Chief Complaint:
    Nausea and vomits

    Additional Complaints:
    Abdominal pain, limp, fever, loss of appetite
    History of illness
    Patient came to the ER with the complaints of nausea and
    vomit since early morning. The complaint felt continuosly
    more than 10 times and vomiting greenish yellow. Initially,
    in early morning patient drank some drinks at outside seller.
    Moreless a month ago on 15th august, patient had surgery,
    appendectomy laparotomy at RS Polri, hospitalized for a
    week. Three days before admission, patient checked the
    operation wound and aff hecting. The patient also complains
    pain on upper abdomen and around operation wounds. The
    pain felt like stabbed and intermittent in whole day. He
    didnt take any medication. And because there is no change,
    patient was taken to UKI. Last defecation was yesterday
    morning, diarrhea (-). Loss of appetite (+), limp (+), history
    of trauma on abdomen is denied, fever (+), problem in
    urinating (-).

    Vital Sign
    General : looks moderate sick
    Conciousness : E4V5M6
    BP: 120/90 mmHg
    RR : 20 bpm
    HR : 128 bpm
    Temp : 37,6 C

    Weight : 41kg
    Ideal body weight 49kg

    HEAD TO TOE

    Head : bruise (-)
    Eyes : Pupil circular, isochoric 3mm/3mm,
    centered, Direct Light Reflex +/+, Indirect Light
    Reflex +/+, CA +/+
    Ear : normal, LCS (-), blood (-)
    Neck : Bruise (-), hematoma (-)





    Thorax :
    - Inspection : bruise (-), movement of chest wall
    symmetrical
    - Palpation : vocal fremitus symmetrically
    - Percussion : sonor right = left
    - Auscultation: Basic breath sound Vesicular
    right=left, wheezing-/-, rhonki-/-.

    Abdomen
    - Inspection : looks flat, bruise (-), dry
    wounds (+) below umbilical
    - Auscultation : bowel sound (+) 2 tpm
    - Palpation : tenderness(+), defense
    muscular (-), bulging (-)
    - Percussion : percussion pain (+),
    hypertympani (+) on all abdomens sides

    + + +
    o
    : Tenderness, Percussion pain
    +
    +
    Clinical picture

    Extremities
    palms look pale, warm acral, capillary refill
    time <2 seconds, oedem (-)
    Working Diagnosis
    Partial ileus obstruction e.c susp abscess
    intraabdomen post laparotomy
    appendectomy a.i. appendicitis perforation
    Laboratorium 1
    Result Normal value
    Natrium 141 136 145 mmol/L
    Kalium 4.3 3.5-5.1 mmol/L
    Clorida 98 99-111 mmol/L
    LED 94 < 10 mm/jam
    Hemoglobin 11.4 14-16 g/dl
    Leukosit 18.5 5-10 rb/uL
    Eritrosit 4.31 4.5-5.5 juta/ml
    Hematokrit 34.4 40-48 %
    Trombosit 485 150-400 rb/uL
    MCV 79.9 82-92 /fL
    MCH/HER 26.4 27-31 pg
    MCHC 33.1 32-36 %
    Laboratorium 2
    Result Normal value
    Retikulosit 1.6 0.5-1.5 %
    Basofil 0 0-1 %
    Eosinofil 0 0-3 %
    Batang 1 2-5 %
    Segmen 94 50-70 %
    Limfosit 5 20-40 %
    Monosit 0 2-8 %
    GDS 121 < 200 mg/dl
    Abdominal X-Ray 3 Positions
    Diagnose
    Partial ileus obstruction e.c abscess
    intraabdomen post laparotomy
    appendectomy a.i. Appendicitis
    perforation
    Surgical site infection superficial
    type
    Treatment
    Non Medicamentosa :
    - Hospitalized
    -Vital sign observation
    - NGT (patient refused)
    -Dower Catheter (patient refused)
    -Pro USG abdomen
    -AGD
    -Fluid balance

    Medicamentosa
    Diet : fasting
    IVFD : 1 RL & 1 Dextrose 5% / 24
    hours
    MM :
    Meropenem 2x1 gr IV
    Ranitidine 2x 50mg IV
    Metronidazol 3x500 mg PO

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