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Surat No
Surat No
Surat No
(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
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
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
14/9/2015
POD II
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