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S/F/31yo
Chief complaint: Pain on the whole abdomen
The pain has been suffered by the patient since 1 days
before admission to Haji Adam Malik Hospital. Firstly,
pain was feel in epigastrium and spread into whole
abdomen. Fever (-), nausea (+), vomiting (+).
Micturation (+), defecation (-), flatus (+).
Present state :
•Awareness : Alert
•BP : 110/80 mmHg
•HR : 85x/i
•RR : 22x/i
•T : 36,8°C
•VAS : 5
Generalized State :
• Head and neck : no abnormality was found
• Chest : no abnormality was found
• Abdomen : in localized state
• Genitalia : male, no abnormality was found
• Extremities : no abnormality was found
Localized State :
• Abdomen :
I : Symmetry, Distention (+)
P : pain on the whole abdomen, muscular rigidity
(+)
P : tympani
A : Peristaltic decrese
• DRE : Perineum usual, loose anal sphincter tone,
ampulla was not filled faeces, smooth mucous,
pain (-). Hand gloves : feces (-), blood (-), mucous
(+).
Laboratory findings:
• Hb/Hct/WBC/PLT : 13,7/41,7/15,1/281
• Na/K/Cl : 130/3,4/104
• Ur/Cr : 15,1/0,61
• Random Blood Glucose :132,3
• Albumin : 3,1
Chest X-ray
Working Diagnose:
• Diffuse Peritonitis d/t susp. Appendicitis
perforation
Treatment
• Nill Per Mouth
• NGT insertion, came out greenish fluid 50cc
• Urine catheter insertion, came out initial clear
yellow urine 100cc
• IVFD Crystalloid
• Antibiotic Injection
• Analgetic injection
• Patient was prepared for appendictomy
laparotomy
Cranial
In Operating theater
• Patient in supine position in General anasthesia ETT, aseptic, antiseptic procedure
• Midline incision, Cutis, subcutis, fascia, peritoneum was opened came out serous
haemorrhage about 500 cc
• Identification of hollow organ, gaster, jejenum, ileum in normal limit
• Appendix, colon, and sigmoid in normal limit
• Identification pancreas, found expand pancreas, sofonifikasi was found,
necroticans pancreas was not found
• Fluid came from retroperitoneal
• Identification gynecology organ, found ovarium cyst size 5 cm  consult at
durante to Obgyn department  drealing was performed
• Bleeding control
• Abdomen fluid was evacuate intermittenly, leaving 2 drain for external draining
• The surgical wound was closed layer by layer
• Operation was done

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Diffuse peritonitis

  • 2. Chief complaint: Pain on the whole abdomen The pain has been suffered by the patient since 1 days before admission to Haji Adam Malik Hospital. Firstly, pain was feel in epigastrium and spread into whole abdomen. Fever (-), nausea (+), vomiting (+). Micturation (+), defecation (-), flatus (+).
  • 3. Present state : •Awareness : Alert •BP : 110/80 mmHg •HR : 85x/i •RR : 22x/i •T : 36,8°C •VAS : 5
  • 4. Generalized State : • Head and neck : no abnormality was found • Chest : no abnormality was found • Abdomen : in localized state • Genitalia : male, no abnormality was found • Extremities : no abnormality was found
  • 5. Localized State : • Abdomen : I : Symmetry, Distention (+) P : pain on the whole abdomen, muscular rigidity (+) P : tympani A : Peristaltic decrese • DRE : Perineum usual, loose anal sphincter tone, ampulla was not filled faeces, smooth mucous, pain (-). Hand gloves : feces (-), blood (-), mucous (+).
  • 6.
  • 7. Laboratory findings: • Hb/Hct/WBC/PLT : 13,7/41,7/15,1/281 • Na/K/Cl : 130/3,4/104 • Ur/Cr : 15,1/0,61 • Random Blood Glucose :132,3 • Albumin : 3,1
  • 9.
  • 10.
  • 11. Working Diagnose: • Diffuse Peritonitis d/t susp. Appendicitis perforation
  • 12. Treatment • Nill Per Mouth • NGT insertion, came out greenish fluid 50cc • Urine catheter insertion, came out initial clear yellow urine 100cc • IVFD Crystalloid • Antibiotic Injection • Analgetic injection • Patient was prepared for appendictomy laparotomy
  • 13.
  • 14.
  • 16. In Operating theater • Patient in supine position in General anasthesia ETT, aseptic, antiseptic procedure • Midline incision, Cutis, subcutis, fascia, peritoneum was opened came out serous haemorrhage about 500 cc • Identification of hollow organ, gaster, jejenum, ileum in normal limit • Appendix, colon, and sigmoid in normal limit • Identification pancreas, found expand pancreas, sofonifikasi was found, necroticans pancreas was not found • Fluid came from retroperitoneal • Identification gynecology organ, found ovarium cyst size 5 cm  consult at durante to Obgyn department  drealing was performed • Bleeding control • Abdomen fluid was evacuate intermittenly, leaving 2 drain for external draining • The surgical wound was closed layer by layer • Operation was done