Morning Report

Sunday, Des 6st, 2015

Team on duty
dr. Tugam
dr. Munawar

RSUDZA

(Jaga I)
(Jaga II)

dr. Jauhari

(Jaga III)

dr. Bobby

(Jaga IV)

dr. Ike Yoganita

(Jaga V)

dr. Iskandar Islam

(Jaga VI)

Patient identity
Name
: Elly
Age
: 39 years old
Sex
: Female
Address
: Dusun pulo pisang , Ds. Cot
Batee, Kec. Kuala, Bireuen
CM : 107 34 71
Phone
: 082363590011
Admission time
: 20.05 WIB

Time Response
Date/ho
ur
patient
came to
ER

Examin
ation
hour

6st
2015
20.05

20.05

Des

Laboratory
Examination

Radiology
Examination

Hour of Date/ho
Diagnos
ur
tics
patient
Resul
out
t
from ER

Send

Resul
t

Send

20.15

21.30

20.25

21.20

21.20

16.00

DPJP

Dr.
Muntad
har
SpB.
Sp.BA

Chief complaint:
Abdominal distension
Present illness history
Patient referred from district hospital dr.
Fauziah Biereun to Zainoel Abidin
emergency room with a chief complaint
abdominal distension for 2 weeks and
getting worst in a week. The patient had
history of diarrhea since 2 months ago,
history of defecation and flatus (-) for a
week, history lost of body weight (+),
history of nausea and vomitting (+).

Physical examination
General condition
: Moderate
Blood Pressure : 130/80 mmHg
Heart rate
: 96 beats/ minutes
Respiratory rate : 24 breaths/minutes
Body temperature
: 37,2C
L/S at the abdominal region :
I : symmetrically, distension (+), darm
countour (+),
visible peristaltic (-)
A: bowel sound (+) increased
P: pain (-), muscular rigidity (-)
P: tympani (+), liver dullness (-)
IAP: 15 mmhg IAH grade I

Digital Rectal Examination

Tight sphincter ani
Smooth mucose
Ampula colaps
Mass (-)
Glove : faeces (-), blood (-), mucous (-)

Assessment:
1.Total mechanical bowel obstruction due
to susp. colorectal cancer
2.SIRS
3.Intra Abdominal hypertension grade I

Management
Stop oral intake
IVFD RL Resuscitation
NGT decompression feces
Urine catheter
Ceftriaxone Inj. 1 g
Ketorolac Inj. 30 mg
Ranitidin Inj. 50 mg
Laboratory examination
Radiology examination

Time

BP

HR

21.00

130/80

96

22.00

130/90

86

23.00

130/90

00.00
01.00

120/80
120/90

82

RR
24
20
22

Urine

37,2

10 cc

36,6

30 cc

36,4

50 cc

84

24

36,4

40 cc

110

20

36,7

40 cc

02.00

130/90

94

22

36,6

30 cc

03.00

130/100

84

22

36,7

45 cc

04.00

120/80

82

20

36,2

50 cc

Laboratory result
Hemoglobin
White Blood Count
Platelets
Hematocrit
CT/BT
Ur/Cr
Pottasium
Sodium
Chloride

: 12,7 gr/dl
: 4.600 / ul
: 496.000/ul
: 40 %
: 7/2
: 52 / 0,67
: 3,5
: 137
: 102

AGDA
PH
PCO2
PO2
HCO3
TotalCO2
BE
Saturasi 02

:
:
:
:
:
:
:

7,479 mmhg
32,60 mmhg
93 mmhg
24,5 mmol/L
25,5 mmol/L
2,1
97,5 %

Radiologi result
Thorax AP cor and pulmo in normal
limit
Abdomen 2 position :
Air distribution not until distal
Dilatation of bowel (+)
Hearing bone (+)
Step ladder (+)

Diagnose :
1.Total mechanical bowel obstruction due to
susp. colorectal cancer (ICD CM 10 K56.69)
2.Sepsis (ICD CM 10 A41.9)
3.Intra Abdominal hypertension grade I (ICD
CM 10 M79.A3)
Consult to Digestive Surgery division :
Laparotomy exploration emergency +
colostomy

Operative Report :
Perform mediana insicion 2 cm upper umbilical until
2 cm simpisis pubis layer by layer until peritonium
Found dilatation colon, ileum and yeyenum
Continued exploration whole intra abdomen found
tumor mass 4 cm upper reflection of peritonium
Perform resection tumor mass
Perform decompretion yeyenum ileal and colon
proximal
Perform hartman procedure with stepler 75mm
( 4cm from distal tumor and 7cm from proximal
tumor)
Perform appendectomy incidental
Perform colostomy

Post Op Diagnose
1.Total mechanical bowel obstruction
due to colorectal cancer (ICD CM 10
K56.69)
2.Sepsis (ICD CM 10 A41.9)
3.Intra Abdominal hypertension grade
I (ICD CM 10 M79.A3)

Follow up
Date

11/12
/
2015
POD
4

Pain
(+)
decr
ease

General condition :
good
BP : 110/80 mmHg
RR : 20 breaths/min
HR : 78 beats/min

Post Laparotomy
explorasi +
Tumor Resection
+ Hartman
prosedure with
stapler +
appendectomy
incidental

Diet ML
IVFD
Futrolit:Asering
20 drip/min
Clinimix+Eveli
p 1 Fls/day
L/S at Abdomen
Inj ceftriaxone
I : Wound dry
1gr/12Hr
Stoma
Metronidazole
Viable,production
1.Total mechanical 500mg/8Hr
(+)
bowel obstruction Inj Antrain
A : Bowel sound (+) due to susp.
1amp/8Hr
P : Pain (+)
colorectal cancer Inj Ranitidin
Decrease,Soepel
50mg/12Hr
(ICD CM 10
P : Tymphani
Drip Albumin
K56.69)
20% 100cc
2.Sepsis (ICD CM
Drain : 80cc ( Serous 10 A41.9)
)
3.Intra Abdominal
Urine 24Hr : 700cc hypertension