Department of SurgeryJanuary 29, 2015

Name: Mr. S Age: 60 y.oSex: MaleAddress: Sumberwungu ModoDate examination: Jan 29, 2015

ANAMNESISChief complaint Abdominal painPresent IlnessPatient complained abdominal pain since 1 days before admission. It was suddenly. It started from epigastric. Then, Abdominal pain at all of abdominal quadrant continuely. Nausea +, vomit -, febris -, he couldnt defecation since 3 days before. Miction was normaly.

Airway and spine control : clear (+), snorring (-), gargling (-), potensial obstruction (-)Breathing : spontan, simetric (+), RR 24x/minutes, ves/ves, rh-/-, wh-/-Circulation : PR 106x/minutes, acral warm dry red, CRT < 2, Sp02 distal 100%, blood presure130/79 mmHgDisability : GCS 456, LP +/+, isocor pupil 3mm/3mm, lateralisasi-Exposure : temp 37

History past illness HT denial, maag +, injury denialHistory of social, economic : herbal medication (+)Status GeneralisHead and neck : anemic (-), icteric (-), cyanosis (-), dyspneu (-)Thorax : simetric (+), retraction (-)Pulmo : ves/ves, rh-/-, wh-/-Cor : S1S2 single, murmur (-), gallop (-), lession -Abdomen : defans (+), tympani (+), liver and spleen were not palpable, bowel sound (+), lession-Extremities : acral warm, dry, red, lession-

Clue and cueMale 60 y.o.Abdominal pain at all of abdominal quadranKonstipasi (+)Abdomen : Defans +

AssesmentPeritonitis susp. Ec perforasi gaster

CBCBGAThorax photoBOF LLD

Lab Diff : 0/0/89/9/2Hct : 38,5Hb : 12,2LED : 44/67Leukosit : 7600Trombosit : 256.000Urea : 51Creatinin serum : 1.0Clorida : 107Kalium : 3,49Natrium 146Be 1.0Beecf 0,4HCO3 24,1Hct 39PCO2 34,5Ph : 7,444PO2 69,7SO2 94,8

Thorax Photo

BOF

LLD

Assesment Peritoniti EC Perforasi gaster DD Perforasi colon.

02 nasal 4 lpmNGT Catheter foleyIvfd Asering loading 2000cc Inj.Metronidazole 3x500 mgInj. Ceftriaxon 2x1 g ivInj santagesic 3x1 amp ivInj acran 2x1 amp ivc/ Sp.B Cito pro laparotomy c/ Sp.An

Subjective complaintVital sign

Explain to the patients family about the diagnosis, etiology, intervention of therapy, complication, and prognosis.

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