CASE REPORT

Tuesday, August 4th 2015

Team on duty
dr. M. Nazir Tambunan
dr. Tommy Rivelino
dr. Andri Mulia
dr. Bobby HE Fermi
dr. Herdi Gunanta S
dr. Syahmardani Ibnu

(Jaga 1)
(Jaga 2)
(Jaga 3)
(Jaga 4)
(Jaga 5)
(Jaga 6)

Patient identity
Name
: Suratno
Age
: 54 years old
Sex
: Male
Address
: Kuala pesisir, nagan raya
MR
: 1 06 40 67
Phone
: 08526033387
Patient came : 10.00 PM
Body weight : 98 kg
Date/h Examinati Laboratory
Radiology
Hour of
our
on hour
Examination Examination Diagno
patien
stics
t came
Sen Result Send Result
to ER
d
Sept,
12th,
2015
20.30

20.30

20.40 21.50

20.45 21.00 21.00

Date/ho DPJP
ur
patient
out
from ER
Dr.
Jufriady
Ismy SpU

Chief complaint
Abdominal distention.
Patient illnes history
The patient was referred from RS Tgk FAKINAH to emergency room with a chief
complain abdominal distention for 8 day. Initially, patient can not defecation and
flatulency anymore. History of vomiting (+).There was history of bowel habit
changes (+).
.

Physical examination
Vital Sign
Blood Presure
: 200 / 109 mmHg
Pulse
: 115 beats / minute
Respiratory rates : 32 breaths /minute
Rectal temperature : 38 oC
Localize state :
Abdominal
Inspection
: Distension(+), bowel contour (-)
Auscultation
: Bowel sound (+) increase
Palpation
: Pain (+), Muscular rigidity (-).
Percussion
: Liver dullness (+)
IAP examination: 26 cmH2O 20 MmHg
Digital rectal examination
Tight sphincter ani, collaps ampula recti, smooth mucosa, pain (+), At glove :
feaces (+) blood (-) mucous (-)
Radiologic Examination
Thorax erect
In normal limit
Abdominal two position
Dilatation of colon
Air fluid level
Assessment
Total mechanical bowel obstruction ec. Susp. Colorectal tumor
Intra abdominal hypertension
Hypertension
Management
Stop oral intake
NGT unclear
Oxygen 4 liter/i via nasal canul
Urine Catheter initial 40 cc
IVFD RL 2000 cc
Ceftriaxone 2 g
Ranitidine 150 mg
Laboratory examination
Time
urine

23.00
00.00
01.00
02.00
03.00
04.00
05.00
06.00

40 cc
30 cc
40 cc
40 cc
30 cc
45 cc
40 cc
45 cc

VAS : Moderate

Laboratory examination :
Hemoglobin
WBC
Platelet
CT/BT
HT
Na
K
Cl
Blood glucose random

: 11,3 gr/dl
: 9.900 mg %
: 437 x 103/ul
: 9/3
: 39 %
: 139 mmol/L
: 3,9 mmol/L
: 99 mmol/L
: 134 mg/dl

Diagnose
Total mechanical bowel obstruction ec. Susp. Colorectal tumor ( ICD 10 K56.69)
Intra abdominal hypertension (ICD 10 CM 789.3)
Hypertension (ICD 10 I15)
Consult to digestive surgery division :
Emergency laparotomy exploration

Preparation for colostomi

Consult to cardiology division :

Perdipine drip 0,1 mg/kgBB/hours high risk for operation, advise perfomed
echocardiografi
Acute anterior extensive STEMI + infark inferior postpone the operation
because high risk
Informed consent the family accept all of risk for operation include DOT
Consult to anesthesiology
Agree with cardiology division to postpone the operation
Patient hospitalize in the PJT Rom
Follow Up
Date

persistent
12/09/2015 pain and
Ad 1
abdominal
distension

O
Vital Sign :
BP : 194/100 mmHg
RR : 32 breaths/mnt
Pulse : 126 beats/mnt
NGT : clear
L/S at the abdominal
region :
Abdominal
Inspection
:
Distension
Auscultation : Bowel
sound (+) increase
Palpation
: pain (+)
Muscular rigidity (-).
Percussion
: Liver
dullness (+)
IAP : 28 22 MmHg

Operative Report :
Mid line incision, dilatation of bowel

Total mechanical
bowel obstruction
ec. Susp.
Colorectal tumor
Intra abdominal
hypertension
Hypertension

Stop Oral intake

IVFD RL 30 drips /
minute
Inj Cefriaxone 1gr/12
hours
Metronidazole 500 mg/8
hours
Inj Ranitidin 30 mg/8 hour
Ketorolac inj/8 hours
Reconsult to
anasthesiology
Performed laparotomy
exploration emergency

Explore until distal, found mass from sigmoid to serosa

Exploration to liver no mass palpeble
Perform reseksi colon sigmoid
Primary closure distal stump sigmoid
Perform ileostomy and decompression
Perform colostomy
Node Biopsy

Post Operative Diagnose

1. Total mechanical bowel obstruction due to susp. Ca sigmoid T3N1M0 ( ICD 10
K56.69)
2. Intra abdominal hypertension (ICD 10 CM 789.3)
3. Hypertension (ICD 10 CM I15)
Follow Up
Date

14/9/2015
POD II

Pain (-) Vital Sign :

Post Laparotomy
GCS : On Ventilator
eksploration + end
(CMV,FiO2 50%)
colostomy + Primary
BP : 194/100 mmHg
closure stump distal
RR : 29 breaths/mnt
1. Total mechanical
Pulse : 126 beats/mnt
bowel obstruction
Spo2 : 98%
due to susp. Ca
L/S at the abdominal region :
sigmoid T3N1M0
I : wound operation close by
( ICD 10 K56.69)
gauze, dry (+)
2. Intra abdominal
A: Bowel sound (+)
hypertension (ICD
P: Pain (-)
10 CM 789.3)
P: Liver dullness (+)
3. Hypertension (ICD
IAP ; 20 15 MmHg
10 CM I10)

P
IVFD RL 20 drips /
minute
Inj Meropenem 1gr/12
hour
Inj Ranitidin 30 mg/8
hour
Fentanyl drip 50mq/jam
Propofol drip 60mg/jam
Actalitid 1x40mg
Stop oral intake

Follow up
Date
14-09-15
AD 2

O
Pain ( - )

Vital sign
Blood Pressure :
120/80 mmhg
Pulse : 82 beats/mnt
RR : 20 breaths/mnt
E:L/S at the supra pubic:
L: distention (-)
F:Pain (-)
L/S at the penile:
L: necrotic wound (+),
swelling (+), lacerated
wound (-), F:Pain (+)
Urine : 50 cc / h
(cystostomy)

Urine Retension
Susp BPH
Necrotic penis ec
mekanical iskemic
Akut on CKD ec
retensio kronis
Bilateral
hydronefrosis
Speech impaired
Post
cystostomy

IVFD NaCl 0,9 %

20
drips/minutesInj.
Cefaforazon 1
gr/12hour
drip. metronidazol
500mg/8hour
Inj.Keterolac 3%
1amp/12hr(K/P)
Inj ranitidin
1amp/12jam (k/P)
Kalnex
500mg/8jam
Hospitalize
prepare for Total
Penectomy
elective