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