Time BP HR RR T SpO2 UO KETERANGAN

22.00 80/50 126 28 37.2 92% Initial 400 somnolent

cc, yellow abdomen : distended, tense, bowel sound (+) ↓, tenderness (+), rebound tenderness (+),
muscular rigidity (+), liver dullness (-)
DRE : weak sphincter tone, smooth mucosa, ampulla wasn’t collapsed, tenderness (+) at all
direction
Gloves : stool (+), blood (-)
Intravesical pressure : 11mmHg

Th /
Oxygenation NRM 12 L/m
Fluid resusitation 1000 cc Nacl 0,9%
Blood transfussion prc 250 cc
Decompression with NGT and catheter urine
Ceftriaxone 1x2 gram IV
Omeprazole 2x40 mg IV
Paracetamol 3x1 gr iv
Vascon 0,05 Mcg/KgBB/Mnt
Plan to exploratory laparotomy
CVC insertion
inform consent
Consult to ICU (full)
22 May 2019 100/60 96 26 36,8 96% - somnolent
a/r abdomen : distended, tense, bowel sound (+) ↓, tenderness (+), rebound tenderness (+),
01.00 muscular rigidity (+), liver dullness (-)
Intravesical pressure : 11mmHg
CVP 6 cmh2O

Th /
Oxygenation NRM 12 L/m
Ceftriaxone 1x2 gram IV
Omeprazole 2x40 mg IV
Paracetamol 3x1 gr iv
Vascon 0,05 Mcg/KgBB/Mnt
Plan to laparostomy drainage in local anestesia
Family consent
 Time BP HR RR T SpO2 UO KETERANGAN

22 May 100/60 96 26 37.5 95% - somnolent

2019 a/r abdomen : distended, tense, bowel sound (+) ↓, tenderness (+),
04.00 rebound tenderness (+), muscular rigidity (+), liver dullness (-)
Intravesical pressure : 11mmHg
CVP 7 cmh2O

Th /
Oxygenation NRM 12 L/m
Ceftriaxone 1x2 gram IV
Omeprazole 2x40 mg IV
Paracetamol 3x1 gr iv
Vascon 0,05 Mcg/KgBB/Mnt
Plan to exploratory laparotomy
Consult to ICU (full)
Family refuse to medical advice  patient forced discharged by him self