Gaster Perforation - 8 november 2021-1.pptx

Gaster perforation

1. R/F/55 yo 84. 72 . 29

2. Chief Complaint: Pain on the whole abdomen It ha s been suffered by the patient since 2 day s before admi tted to H. Adam Malik Hospital. Initially , The patient has previousy undergone Laparotomy exploration, primary suture and omental patch due to gaster perforation since 6 days ago. Fever ( - ), nausea (-), vomiting ( - ) , diarrhea ( -), urinate (+) normally, defecation ( - ) since 2 day s ago . History of trauma or traditional massage (-), traditional medicines and pain killer consumption (+), alcohol consumption (-) . Patient was reffered from district hospital.

3. Present state Awareness : A lert BP : 1 0/ 7 0 mmHg HR : 108 bpm RR : 2 2 tpm T : 3 7 , 7 C VAS : 5 BW : 7 kg

4. Generalized State Hea d and neck : no abnormalit y was found Chest : no abnormalit y was found Abdomen : in localized state Genitals : Female, no abnormality was found Ext remit ies : no abnormali t y was found

5. Localized state Abdomen I : symmetric al, distention (+) , midline incision (+) A : peristaltic ( - ) P : tenderness (+) on the whole abdomen, muscular rigidity (+) , pain (+) P : liver dullnes s (-), hypertympani (+) Digital Rectal Examination : Perineum normal , l oose anal sphincter tone, smooth mucosal surface, pain o/t whole clockwise , ampulla was filled with feces . Gloves : stool ( + ), blood (-) mucus (-)

6. Laboratory Findings Hb/ Hct /WBC/ Plt : 8,1 /41/ 1 3 . 85 / 204.000 Glucose ad random : 97 Na/K/Cl : 1 34 / 3. 7 /10 5 Ur/Cr : 71 /0. 67 Alb : 1.7

7. Chest X-Ray

8. Working Diagnos is T erti ary P eritonitis + L eakage G aster P erforation + post P rimary S uture + O mental P atch ( POD 6 ) + Anemia + Hipoalbuminemia

9. Management at ER Nil per mouth IVFD C r y stalloid Ringer lactat 20 drips/min Insertion of urinary catheter  came out clear yellowish urine for about 100 cc, UOP 70 cc/hour Insertion of NGT  came out green ish liquid about 2 00 cc Inj. Cefriaxone 1 gr iv Inj. Paracetamol 500 mg iv Blood transfusion  (10-8,1)70x4= 532cc  3 bag prc Substitution albumin (3,5-1,7)70x0,8= 100 mg Plan: External drainage Exploratory Laparotomy urgency