Morning Report

Tuesday, February 27th 2018

Physician incharge :
IGD : dr Grandy
 SUMMARY OF DATA BASE

Boy A/ 13 yo/ ED
Chief complaint : Abdominal pain

A boy was brought to ER RSL because of whole abdominal pain.

It happened suddenly since yesterday. the patient has been brought
to a doctor and drink medicine but the pain is still there.
His abdominal pain was followed by fever and defecation or flatus
difficulty.
There's no history of trauma in abdominal region.
Decrease of conciousness (-), nausea (+), vomitting (-), bloody
vomit or stool (-), urination was normal.
 History

• Hypertension (-)
• Diabetic mellitus (-)
• Diarrhea (-)
• TB or other lung problems (-)
• There's no hospitalized history before
 Physical Examination
General appearance Looked severely ill
GCS : 4 5 6, W 38 kg
Blood Pressure (ER) 110/ 80 mmHg
Pulse Rate 106 tpm, regular
Respiration rate 24 tpm
T ax 37,2 0C
Head Anemic -/- , ict -/-
Chest Heart reguler, S1 S2 single, murmur -

Lung Symmetric VS D=S , ronchy -, wheezing -

Abdomen Flat, BS (-), defans muscular (+), tenderness (+) whole

quadrant

Extremities Edema -, Strength UE 5/5 LE 5/5, cold acral -

 Laboratory on ER

Laboratory finding Value

Hemoglobine 13,6 gr/dl N: 13,2 – 17,3
Leucocyte 10.260 /µl N: 4.400 – 11.300
Eritrocyte 5,11 /µl 3,80 - 5,20
Hematocryte 40,1 % 35 - 47
Trombocyte 239.000 /µL 150.000 – 440.000
Abdominal Ro
 Data at ER RSL

Physical exam WDx treatment

Looked severely ill Peritonitis IVFD RL
GCS 4 5 6 generalisata Inj santagesic
BP 110/80 HR 106 RR 24 NGT
Acute abdomen ec
Abd: defans muscular, susp ileus paralitic consule dr widanto SpBA
whole quadrant pro exploration laparotomy
tenderness, BS (-)
 Data at WARD RSL

Physical exam WDx treatment

Looked weak Peritonitis Ceftriaxone 2 x 1 gr
GCS 4 5 6 generalisata Metronidazole 3 x 250 mg
BP 110/80 HR 94 RR 20 Antrain 3 x 500 mg
Sepsis Ranitidine 2 x 50 mg
Abd: flat, pain post op
Ileus obstruktif
 Peritonitis
• Spontaneous Peritonitis
– an infection that occurs as a complication of
ascites (related to liver or kidney failure).
• Secondary Peritonitis
– caused by another condition, most commonly
the spread of an infection from the digestive
organs or bowels.
• Dialysis associated Peritonitis
– acute or chronic inflammation of the
peritoneum that occurs in people receiving
peritoneal dialysis
 Symptoms
• Toxic / ill looking
• Nausea, Vomiting
• Abdominal pain, which increases on movement.
• Abdominal tenderness / distension
• Fever
• Point tenderness
• Constipation / Inability to pass faeces gas
• Fluid in the abdomen
• Sign of dehydration / shock in extreme cases.
 Diagnosis
• Abdominal x-ray
• Abdominal ultrasound / CT Scan / MRI
• Full blood count
• Liver function tests
– (liver cirrhosis, Spontaneous bacterial peritonitis)
• Amylase and lipase
– (pancreatitis)
• Blood culture
– (sepsis -> antibiotic)
• Urineanalysis
– (pyelonefritis / UT causes)
• Peritoneal fluid analysis
 Management
• Fluid resuscitation
• Surgical laparoscopic
• Antibiotic therapy
– Gram-positive, gram-negative bacteria and anaerobic coverage
is essential. Agents which are commonly used are cefotaxime,
aminoglycoside, ampicillin, and sulfamethoxazole.Carbapenems
such as Meropenem, Fluroquinolones are also used.
• No operative drainage (Percutaneous drainage)
– Percutaneous drainage under ultrasound or CT guidance for
abscesses
• Therapeutic paracentesis
– Sometimes in patients with ascitis, serial paracentesis are
needed when fluid is keep on accumulating.
 Complications

• Peritonitis stops the movement of bowel

contents (peristalsis), which can block the
bowel (paralytic ileus).
• Septic shock
• Abscess
• Intraperitoneal adhesions
 Differential Diagnosis

• Ruptured Abdominal aneurysm

• Acute Appendicitis / perforated viscus
• Mesenteric Ischemia
• Pyelonephritis
• Granulomatous peritonitis
– Occurs in parasitic infestations, sarcoidosis, tumors,
Crohn's disease, And symptoms due to peritoneal
irritation could occur. [9]
• Gynecologic disorders
– PID, Ruptured ovarian cyst, ectopic pregnancy
 ILEUS : Ileus Causes
• Medication
– hydromorphone (Dilaudid)
– morphine
– oxycodone
– tricyclic antidepressants, such as amitriptyline and
imipramine (Tofranil)
• Intestinal cancer
• Crohn’s disease
– which causes the intestinal walls to get thicker due to
autoimmune inflammation
• Diverticulitis
• Parkinson’s disease
– which affects muscles and nerves in the intestines
 Ileus risk factors
• Electrolyte imbalance, such as those
involving potassium and calcium
• History of intestinal injury or trauma
• History of intestinal disorder, such as
Crohn’s disease and diverticulitis
• Sepsis
• History of irradiation of or near the
abdomen
• Peripheral artery disease
• Rapid weight loss
Ileus
Thank you