1. The document discusses the diagnosis and management of acute abdominal pain, outlining various potential causes and approaches.
2. It emphasizes the importance of the initial 20 seconds for determining if a patient is very ill, ill, or reasonably well to guide initial management and need for consultation. Very ill or ill patients require emergency treatment or surgery.
3. A case study is presented of a 67-year-old man with abdominal pain initially diagnosed with cholecystitis but who deteriorated with perforated appendicitis found at later laparotomy, highlighting how initial diagnoses can change.
24. Pemeriksaan Fisik
• Colok Vagina
– Darah
– Discharge
– Nyeri goyang portio
– Nyeri / masa abnesa
– Ukuran uterus
25. Manegemen Awal
Nyeri Abdomen Acut
• 20 detik pertama diagnosis hanya tiga
– Very ill (mengancam jiwa)
– ill (perlu tindakan segera)
– Reasonably well (elektif)
26. • Very ill
– Mengancam jiwa / going to die
– Cari bantuan
• Perawat resusitasi
• Sesama dokter jaga
• Senior Konsultan diberi tahu
27. • ill (perlu tindakan segera)
– Stabil dalam beberapa jam
– Investigasi segera (urgent)
– Initial diagnosis
– Initial management
28. Reasonably well (elektif)
– Investigasi seperlunya
– Formulat diagnosis
– Terapi simtomatik
– Rujuk poli spesialis elektif
31. CT Scaning
- No significant advantage in DD of AAP
- Delay of necessary treatment
- Routing use not justified
Fast
(Fucus assesment with sonografy for trauma)
- Nilai diagnostik untuk trauma tinggi
32. Laparoscopy Diagnostik
- Early diagnostik laparoskopi may result non
spesifik abdominal pain
- Acurat
- Prompt
- Efficient management of AAP
- Reduces the rate of unnesessary laparatomi
- Increases the diagnosis accuracy
- May be a key to soving the diagnostik dilema of
NSAP
33. Suggesions
- Hal penting untuk dinilai dari AAP
-
Initial diagnostic
Pilihan pemeriksaan pembantu yang tepat
Initial treatment yang tepat
Persingkat length of stay
Cost effectiveness
34. Studi Kasus
Identitas Kasus :
- Laki-laki
- Umur 67 tahun
Tanggal
Klinis
16 Okt 2013
S : Ulu hati nyeri
O : Nyeri tekan ulu hati
B U (+)
A : W.D. / Dispepsi
Kolik Abdomen
P : Alganax
Rebamid
Trolac
Fastro
Jolocid
1x1
3x1
3x1
2x1
1x1
Laboratorium
Lekosit 14000
Radiologi
35. Tanggal
17 Okt 2013
Klinis
Laboratorium
Radiologi
S : Mengeluh sakit sekali
USG :
O : T = 110 / 70
N = 80 S = 36
RR = 20
- Hepar normal
- KE dinding
menebal sedikit
- SLUDGE
- Kesan
cholecystitis
A : W.D. / Dispepsi
Kolik Abdomen
P : Teruskan
18 Okt 2013
S : Sakit + + +
O : USG cholecystitis
dengan sludge
A : Dispepsi Kolik
Abdomen ec
cholecystitis
P : Urdafalk 3 x 1
MST 10 2 x1
HB = 11,2
HT = 34
L = 12000
36. Tanggal
19 Okt 2013
Klinis
Laboratorium
S : Sakit perut +++
Demam +, Batuk
Thoraxfoto :
- Cor normal
- CTR 55%
- Pulmo effusi
pleura kiri
- Sudut
costophrenicus
tumpul
O:
- Nyeri tekan ulu hati
- C/P dalam batas
normal
A:
Dispepsi Kolik Abdomen
ec cholecystitis
P : Terapi lanjutkan
20 Okt 2013
S : status quo ante
Radiologi
- Natrium 133
- Calium 4.0
- CL 107
37. Tanggal
21 Okt 2013
Klinis
S:
- Ku Lemah
- Diare +
O:
- Ku lemah Cm
- T = 120 / 70, N = 84,
S = 36, RR = 20
-C/P tak
- Abdomen nyeri tekan +
- Akral hangat
A:
- Dispepsi Kolik
Abdomen ec
Cholecystitis
- GEA
P:
- Lodia
- Terapi lain teruskan
Laboratorium
- Lekosit 8900
- LED 82
Radiologi
38. Tanggal
22 Okt 2013
Klinis
S:
-Demam naik turun
(catatan perawat)
- BAB cair
- Kedua kaki bengkak
O:
- Ku Lemah
- T = 110 / 70, N = 88,
S = 36, RR = 20
A:
-Dispepsi Kolik
Abdomen ec
cholecystitis
- GEA
P:
- Cek Elektrolit
- Cek Albumin
- Lain2 teruskan
Laboratorium
- Albumin 2.2
- N a = 130
Radiologi
39. Tanggal
23 Okt 2013
Jam 18:15
Klinis
S:
- Perut Kembung
- Nyeri seluruh perut
- Demam (+)
O:
- Ku Lemah Cm
- T = 130 / 70, N = 88
S = 38,3, RR = 20
- C/P tak
- Abdomen kembung
(destended)
- Defance musc (+)
- Hepar/Lien sulit diraba
- Edman (–)
A:
- suspect ileus paralitik
- DD obstruksi
- Dispepsi Kolik
Abdomen ec cholecystitis
dengan SLUDGE
Laboratorium
Jam 19:10
- HB = 11
- L = 19800
- NA = 130
Radiologi
Abdomen 3
posisi, hasil
adalah :
- Preperitonial fat
menebal
- Air fluid level (+)
- Free air (-)
40. Tanggal
23 Okt 2013
Jam 18:15
Klinis
A:
- GEA
- Hipo Albumin
P:
- Konsul SPB
- Puasa
- NGT dekompresi
- Abdomen 3 posisi
- Albuminar 100 25%
- DPL
- Elektrolit ulang
Laboratorium
Radiologi
41. Tanggal
23 Okt 2013
Jam 20:43
Klinis
Laboratorium
Radiologi
S : Sakit seluruh perut
Jam 23:32
Usg :
O:
- Keadaan umum
kesakitan
- T = 110 / 70, N = 88
S = 36, RR = 20
-C/P tak
- HB = 10,5
- HT = 31
- L = 20800
- T = 421
- Cholelithiasis
- Abdomen 3
posisi
- Air fluid level (+)
- Preperitoneal fat
menebal
- Kesan peritonitis
umum
Abdomen
- Destended
- Peritonitis (+)
- Bu (-)
- Nyeri tekan (+)
- Nyeri lepas (+)
- Defance Musc (+)
A:
- Peritonitis umum
- APP perforasi
- Cholecystitis ruptur
42. Tanggal
23 Okt 2013
Jam 20:43
Klinis
P:
- Infus teruskan
- Puasa
- NGT kateter tampung
ukur
- Anjuran ekplorasi
- Laparatomi cito
-Terapi tambah
- Trichodasol 1 x 1,5 gr
Laboratorium
Radiologi
45. Take home messages :
1. Initial diagnosis :
- Very ill (mengancam jiwa)
- ill (perlu tindakan segera)
- Reasonably well (elektif)
2. Very ill dan ill -> konsul Spb
Reasonably well -> konsul poliklinik bedah
3. DD
- Infeksi intra abdomen
- Obstruksi GI tract
- Bleeding intra abdomen
- Ischemia organ intra abdomen