Morning Report

Sunday, June 25th 2017

Team on duty
dr. Nizarli (Chief)
dr. Tommy Rivelino (Jaga 1)
dr. Zumirda (Jaga 2)
dr. Nasrul Haidi (Jaga 2)
dr. M. Reza (Jaga 3)
dr. Bobby H.E Fermi S (Jaga 3)
dr. Herdi Gunanta (Jaga 4)
dr. Avisenna Gatot Purnomo (Jaga 4)
dr. Novli Ardiansyah (Jaga 5)
dr. Jufrialdy (Jaga 6)
dr. M. Iqbal (Jaga 6)
dr. Ricky Aldofan (Jaga 7)

Patient identity
Name : Bismil Huda
Age : 34 years old
Sex : Male
Address : Ds. Jagung, Pegasing , Takengon
Phone : 0823 6547 765
MR : 113 76 16
Admission Time : 01.45 AM

Chief Complaint
Abdominal distension

Patient illnes History

The patient was referred from Takengon District Hospital to Zainoel Abidin with chief
complaint Abdominal distension since 5 days ago.
The patient also complaint was unable to defecation and flatus for 3 days
There was history nausea and vomiting (+)
History of change bowel habit (+), decrease of body weight (+)
History of colonoscopy 2 years ago with result tumor ascenden colon (well differentiated
adenocarcinoma), but the patient refused medical advise.

Physical examination
Vital sign
BP : 120/80 mmHg
RR : 22 beats/minute
HR : 92 beats/minute
 Temp : 37,2 C
SL abdomen
I : Symetrically, distension (+), bowel contour(-), bowel movement(-)
A : Bowel sound (+) increased
P : Pain (-), defans musculair (-)
P : Tympani (+), liver dullness (-)
IAP : 18 mmHg
Digital rectal examination
Spinchter ani : Tight
Ampula : Collapse, mass (-)
Mucosa : Smooth
Handscoen : Faeces (-), blood (-)

Assessment
1. Total mechanical bowel obstruction due to susp. Tumor colorectal
2. Intra-abdominal hypertension grade II

Management
Stop Oral Intake
NGT 150 cc -- > yellowish
Catheter initial 60 cc clear
IVFD RL 1500 cc/24 hours
Inj. Ceftriaxone 1 g
Inj. Tramadol 50 mg
Laboratory examination
Radiology examination

Laboratory result
Hb : 14,2 gr/dl
WBC : 6.600/ul
Platelet : 278.000 /ul
HT : 29%
CT : 7 minute
BT : 2 minute
Potassium : 3,2 mmol/dL
Sodium : 136 mmol/dL
Clorida : 104 mmol/dL
Ureum : 66 mmol/dL
 Creatinine : 1,40 mmol/dL

Thorax AP
In normal limit

Abdomen 2 position
There is bowel dilatation
There is air fluid level
Bowel gas is not until distal

Diagnose:
1. Total mechanical bowel obstruction due to susp. Tumor colorectal
2. Intra-abdominal hypertension grade II

Consult to digestive surgery division :

Laparatomy exploration emergency

Operative report
Performed midline incision
Peritoneum was opened found dilatation jejenum, ileum until descenden colon
Exploration from Treitz ligament to distal found mass at colon descenden
Identification liver surface regular and no node
There is no node enlargement
Performed hartmant procedure ( resection colon descenden + primary sigmoid closure +
Performed colostomy )
Tumor was sent to PA Lab
Performed 2 tube drain
Wound close by primary suture

Diagnose Post Operative

1. Total mechanical bowel obstruction due to tumor colon descenden (ICD 10 CM K56.0)
2. Intra-abdominal hypertension grade II (ICD 10 CM M79.3)