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Laporan Kasus Perforasi Gaster

1. The patient, a 59-year-old male, presented with abdominal pain and was diagnosed with diffuse peritonitis due to suspected gastric perforation based on physical exam findings and imaging. 2. He underwent an exploratory laparotomy which found a 1.5 cm perforation at the pre-pyloric stomach along with pus and fibrin in the abdominal cavity. The perforation was closed with sutures and an omental patch. 3. Over subsequent days, the patient showed signs of improvement with decreasing drainage output and improved vital signs and lab values, while being treated with IV antibiotics and supportive care.

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149 views29 pages

Laporan Kasus Perforasi Gaster

1. The patient, a 59-year-old male, presented with abdominal pain and was diagnosed with diffuse peritonitis due to suspected gastric perforation based on physical exam findings and imaging. 2. He underwent an exploratory laparotomy which found a 1.5 cm perforation at the pre-pyloric stomach along with pus and fibrin in the abdominal cavity. The perforation was closed with sutures and an omental patch. 3. Over subsequent days, the patient showed signs of improvement with decreasing drainage output and improved vital signs and lab values, while being treated with IV antibiotics and supportive care.

Uploaded by

reza
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LAPORAN KASUS

IDENTITAS
Nama : Tn. D
JK : Laki-laki
TL : 13-2-1958 (59thn)
MRS : 24-3-2017
MR : 998925
ANAMNESIS

Keluhan Utama:
Nyeri seluruh perut

Riwayat Perjalanan Penyakit:


2 hari SMRS, penderita mengeluh nyeri seluruh perut,
mual (-), muntah (-), BAB (-), Flatus (-)
Riwayat minum obat rematik sejak 2 bulan SMRS
(Rujukan dari RS Banyuasin)
PEMERIKSAAN FISIK
Status Generalis
Sens : CM
TD : 110/80 mmHg
Nadi : 96 x /mnt
RR : 22 x / mnt
T : 37,1 C
STATUS LOKALIS
Regio Abdomen
I : Datar
P : Defans musculer (+)
P : Timpani, pekak hati menghilang
A : BU (-)

RT : TSA baik, mukosa licin, ampula


tidak kolaps
HS : Feses (+), darah (-)
NGT : Kekuningan
PEMERIKSAAN PENUNJANG
RONTGEN THORAX AP:
FREE AIR (+)
Foto Polos Abdomen 3 posisi
(RSUD Banyuasin)
Distensi Usus Halus (-)
Herring Bone (-)
Free Air (+)
Air Fluid Level (-)
USG FAST:
CAIRAN BEBAS (+)
LABORATORIUM (24-3-2017)
Laboratorium Hasil Nilai Rujukan

Hb 12 gr/dl 14-18 gr/dl

Ht 38 vol% 40-48 vol %

Leukosit 4000 mm3 5.000-10.000 mm3

Trombosit 188.000 mm3 200.000-500.000 mm3

Na 139 mmol/L 135-155 mmol/L

K 6,0 mmol/L 3,5-5,5 mmol /L

Ureum 136 mg/dl 16-48 mg/dl

Kreatinin 4,41 mg/dl 0,7-1,2 mg/dl

GDS 62 mg/dl <200 mg/dl

PO2/FiO2 535,2 -

pH 7,335 7,35-7,45

pCO2 37,1 35-45

pO2 111,9 83-108

HCO3 20,0 21-28

BE -6,1 (-2)-(+3)
LABORATORIUM POST KOREKSI (24-3-2017)
Jenis pemeriksaan Hasil Nilai rujukan

Na 138 mmol/L 135-155 mmol/L

K 5,2 mmol/L 3,5-5,5 mmol /L

Ureum 148 mg/dl 16-48 mg/dl

Kreatinin 4,42 mg/dl 0,7-1,2 mg/dl


DIAGNOSA

Peritonitis diffusa ec. Susp perforasi gaster


PENATALAKSANAAN

- IVFD RL gtt xxx/ mnt ( kebutuhan cairan 2100 cc / 24 jam)


- NGT, Catheter
- Injeksi Cefriaxon 1 g tiap 12 jam
- Inj metronidazole 500 mg tiap 8 jam
- Koreksi kalium
- Rehidrasi
- Laparotomi cito
INTRA OPERATIF
1. Didalam cavum abdomen didapatkan pus, fibrin dan
bowel content + 2000 cc
2. Pada identifikasi lanjut didapatkan perforasi gaster
pada bagian pre pyloric 1,5 cm
3. Dilakukan refreshing tepi luka jaringan di PA-kan
4. Perforasi dijahit dengan benang silk 2.0 satu-satu
dilanjutkan dengan omental patch
DIAGNOSIS POST OP
Perforasi Gaster Prepyloric
FOLLOW UP (25-3-2017)
S: belum dapat dinilai
O: sens : DPO
TD : 130/80 mmHg
Nadi : 78x/menit
RR : ETT + SIMV PEEP 5 FiO2 40%
T : 36,7 C
Regio Abdomen
I : datar, kassa op kering, NGT : hijau
drain I : 300 cc/24 jam
drain II : 250 cc/24 jam
P : lemas
P : tympani
A : bising usus (+)
A : Perforasi gaster pre pyloric post laparotomi eksplorasi Hari ke 1

P:
IVFD RL:D10%:Kabiven 1:1:1 gtt xxx/m
Puasa
Inj meropenem 1 gr/8 jam IV
Inj omeprazol 40 mg/24 jam IV
Inj metoklopramid 10 mg/8 jam IV
Inj paracetamol 1 gr/8 jam IV
Inj dexmedetomidine 0,2-0,7 g/kgBB/jam IV
Hasil PA tanggal 5-4-2017
LABORATORIUM
Laboratorium Hasil Nilai rujukan

Hb 9,9 gr/dl 14-18 gr/dl

Ht 32 vol% 40-48 vol %

Leukosit 6600 mm3 5.000-10.000 mm3

Trombosit 150.000 mm3 200.000-500.000 mm3

Na 141 mmol/L 135-155 mmol/L

K 6,2 mmol/L 3,5-5,5 mmol /L

Ureum 158 mg/dl 16-48 mg/dl

Kreatinin 3,91 mg/dl 0,7-1,2 mg/dl

Albumin 3,1 g/dl 3,5-5,0 g/dl

PO2/FiO2 130,3 -

pH 7,292 7,35-7,45

pCO2 54,9 35-45

pO2 52,1 83-108

HCO3 26,8 21-28

BE 0,0 (-2)-(+3)
FOLLOW UP (26-3-2017)
S: Belum dapat dinilai
O: Sens : E4M6VT
TD : 135/86 mmHg
Nadi : 88x/menit
RR : ETT + SIMV PEEP 5 FiO2 40%
T : 36,7 C
Regio Abdomen
I : datar, kassa op kering, NGT hijau
drain I : 300 cc/24 jam
drain II : 100 cc/24 jam
P : lemas
P : tympani
A : bising usus (+)
A : Perforasi gaster pre pyloric post laparotomi eksplorasi Hari
ke 2
P:
IVFD RL:D10%:Kabiven 1:1:1 gtt xxx/m
Puasa
Inj meropenem 1 gr/8 jam IV
Inj omeprazol 40 mg/24 jam IV
Inj metoklopramid 10 mg/8 jam IV
Inj dexmetomidin 0,2-0,7 g/kgBB/jam IV
LABORATORIUM
Jenis pemeriksaan Hasil Nilai rujukan

Hb 8,3 gr/dl 14-18 gr/dl

Ht 27 vol% 40-48 vol %

Leukosit 4.900 mm3 5.000-10.000 mm3

Trombosit 129.000 mm3 200.000-500.000 mm3

Na 140 mmol/L 135-155 mmol/L

K 5,5 mmol/L 3,5-5,5 mmol /L

Ureum 173 mg/dl 16-48 mg/dl

Kreatinin 3,71 mg/dl 0,7-1,2 mg/dl

Albumin 3,3 g/dl 3,5-5,0 g/dl

PO2/FiO2 397,3 -

pH 7,371 7,35-7,45

pCO2 50,1 35-45

pO2 158,9 83-108

HCO3 29,3 21-28

BE 3,9 (-2)-(+3)
FOLLOW UP (27-3-2017)
S: belum dapat dinilai
O: sens : DPO
TD: 125/87 mmHg
N : 85x/menit
RR: ETT + SIMV PEEP 5 FiO2 40%
T : 36,7 C
Regio Abdomen
I : datar, kassa op kering, NGT hijau : 200cc/24 jam
drain I : 20 cc/24 jam
drain II : 50 cc/24 jam
P : lemas
P : tympani
A : bising usus (+)
LABORATORIUM
Laboratorium Hasil Nilai rujukan

Hb 8,9 gr/dl 14-18 gr/dl

Ht 27 vol% 40-48 vol %

Leukosit 5.500 mm3 5.000-10.000 mm3

Trombosit 106.000 mm3 200.000-500.000 mm3

Na 148 mmol/L 135-155 mmol/L

K 5,0 mmol/L 3,5-5,5 mmol /L

Ureum - mg/dl 16-48 mg/dl

Kreatinin - mg/dl 0,7-1,2 mg/dl

Albumin 3,3 g/dl 3,5-5,0 g/dl

PO2/FiO2 430,9 -

pH 7,422 7,35-7,45

pCO2 43,8 35-45

pO2 172,3 83-108

HCO3 28,7 21-28

BE 4,1 (-2)-(+3)
A : Perforasi gaster pre pyloric post laparotomi eksplorasi Hari
ke 3
P:
IVFD RL:D10%:Kabiven 1:1:1 gtt xxx/m
Puasa
Inj meropenem 1 gr/8 jam IV
Inj omeprazol 40 mg/24 jam IV
Inj metoklopramid 10 mg/8 jam IV
Inj paracetamol 1 gr/8 jam IV
Inj dexmetomidin 0,2-0,7 g/kgBB/jam IV
FOLLOW UP (28-3-2017)
S: belum dapat dinilai
O:
sens : E4M6VT
TD : 117/71 mmHg
Nadi : 68x/menit
RR : ETT + PS PEEP 5 FiO2 40%
T : 36,8 C
Regio Abdomen
I : datar, kassa op kering, NGT hijau : 150cc/24 jam
drain I : 20 cc/24 jam
drain II : - cc/24 jam
P : lemas
P : tympani
A : bising usus (+)
LABORATORIUM
Laboratorium Hasil Nilai rujukan

Hb 10,2 gr/dl 14-18 gr/dl

Ht 30 vol% 40-48 vol %

Leukosit 7.100 mm3 5.000-10.000 mm3

Trombosit 116.000 mm3 200.000-500.000 mm3

Na - mmol/L 135-155 mmol/L

K - mmol/L 3,5-5,5 mmol /L

Ureum - mg/dl 16-48 mg/dl

Kreatinin - mg/dl 0,7-1,2 mg/dl

Albumin - g/dl 3,5-5,0 g/dl

PO2/FiO2 390,6 -

pH 7,421 7,35-7,45

pCO2 46,8 35-45

pO2 156,2 83-108

HCO3 30,7 21-28

BE 6,1 (-2)-(+3)
A : Perforasi gaster pre pyloric post laparotomi eksplorasi Hari ke 4
P:
IVFD RL:D10%:Kabiven 1:1:1 gtt xxx/m
Diet Clear Fluid 15 cc/2 jam
Inj meropenem 1gr/8 jam IV
Inj omeprazol 40mg/24 jam IV
Inj paracetamol 1 gr/8 jam IV
Inj morphin 10mcq/kgBB/jam IV
FOLLOW UP (29-3-2017)
S: tidak ada
O:
sens : E4M6V5
TD : 169/90 mmHg
Nadi : 93 x/menit
RR : 20 x/menit
T : 36,8 C
Regio Abdomen
I : datar, kassa op kering, NGT hijau : 100cc/24 jam
drain I : 100 cc/24 jam
drain II : - cc/24 jam
P : lemas
P : tympani
A : bising usus (+)
LABORATORIUM
Laboratorium Hasil Nilai rujukan

Hb - gr/dl 14-18 gr/dl

Ht - vol% 40-48 vol %

Leukosit - mm3 5.000-10.000 mm3

Trombosit - mm3 200.000-500.000 mm3

Na 143 mmol/L 135-155 mmol/L

K 4,4 mmol/L 3,5-5,5 mmol /L

Ureum 119 mg/dl 16-48 mg/dl

Kreatinin 1,41 mg/dl 0,7-1,2 mg/dl

Albumin 3,3 g/dl 3,5-5,0 g/dl

PO2/FiO2 - -

pH (darah vena) 7,404 7,35-7,45

pCO2 (darah vena) 53,2 35-45

pO2 (darah vena) 40,6 83-108

HCO3 (darah vena) 33,5 21-28

BE (darah vena) 8,6 (-2)-(+3)


A : Perforasi gaster pre pyloric post laparotomi eksplorasi Hari
ke 5
P:
IVFD RL:D10%:Kabiven 1:1:1 gtt xxx/m
Diet clear fluid 15cc/24 jam
Inj meropenem 1gr/ 8 jam IV
Inj omeprazol 40 mg/24 jam IV
Inj paracetamol 1 gr/8 jam IV
Inj morphin 10mcq/kgBB/jam IV

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