Post on 11-Jan-2016
description
No. Name : Mr. B Sex : MaleAge : 58 years old No. Reg : 630133
Main complaint : Bloating on left stomach
History taking : The complaint had been apparent for 1 week. It started in the small size and now become bigger and felt pain. There were no events of vomiting and fever before.
Defecation : Normally
Micturation : Normally
Physical Examination
General Conditions:Moderate illness/well nourish/composmentis
Vital sign:BP : 120/80 mmHgPR : 88x/mnt, regular, adequate.RR : 24x/mnt.T(Ax) : 37,9 °C
PHYSICAL EXAMINATIONAbdomen
I : Seen bloat size 11 x 11 cm, reddish
A : Bowel sound normally
P : Tenderness (+), solid, warm
P : Tympani
Laboratory ResultWBC : 9,98 x 103 /μL
RBC : 3,28 x 106/μL
HGB : 9,2 g/dL
HCT : 28 %
PLT : 342 x 103/μL
CT / BT : 8’30”/3’30”
Blood Sugar : 120 mg/dl
Ureum : 27 mg/dl
Creatinin : 0,6 mg/dl
SGOT/SGPT : 23/30 u/l
WORKING DIAGNOSIS : Abscess at left upper abdomen
MANAGEMENT : Apply IVFD Medicaments Consult to Senior Digestive Surgeon advice : Drainage
OPERATION PROCEDURE
- Laid the patient down onto undr GA- Disinfection and draping procedure- Proceed inline incision- Evacuate the pus about 200 cc- Spooling the wound with NaCl until clean- Proceed 1 drain and stitched the wound- Done
POST OP DIAGNOSIS : Abscess at left upper abdomen
PROGNOSIS : Good
FOLLOW UP Vital sign