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 sickConciousness : E4V5M6BP: 120/90 mmHgRR : 20 bpmHR : 128 bpmTemp : 37,6 ºC

Weight : 41kgIdeal 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 abdomen’s 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 valueNatrium 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 valueRetikulosit 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

MedicamentosaDiet : fastingIVFD : 1 RL & 1 Dextrose 5% / 24 hours

MM : Meropenem 2x1 gr IVRanitidine 2x 50mg IVMetronidazol 3x500 mg PO