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No.

Name : Mr. U Sex : Male


Age : 21 years No. Reg : 653015

Chief complaint : Abdominal Pain


History taking : Suffered since hours before admitted to the
hospital. Initially he felt pain at the right upper
abdomen. Then spread throughout the abdomen.
Followed by nausea, vomiting and no fever. Pain
increased when he moving and coughing.

Defecation : Normal
Micturated : Normal
Physical Examination

General Conditions:
Moderate illness / well nourish / conscious

Vital sign:
BP : 120/70 mmHg
PR : 76 x/mnt, regular, adequate.
RR : 21 x/mnt.
T(Ax) : 37 C
PHYSICAL EXAMINATION
Abdomen
I : Seen convex, follow breath motion, no bowel contour, no bowel
motion, no tumor mass.

A : Decreased of Bowel sound

P : Tenderness at whole abdomen ,Muscular defans (+) at whole abdomen

P : Tympani
Rectal Toucher

Sphincter ani was tight,


Mucous was smooth,
Ampula filled with faeces,
No palpable mass,
No pain at palpation

Gloves : Faeces (+), blood (-), slime (-)


Laboratory Result
WBC : 17,9 x 103 / L Na : 126

RBC : 5,09 x 106 / L K : 3,4

HGB : 13,4 g/dL Cl : 97

HCT : 40,1 % HbsAg Non reactive

PLT : 302x 103 / L Anti HCV Non reactive

CT / BT : 230 / 700 Albumin 3,8

Blood Sugar : 101 mg/dl

Ureum : 43 mg/dl

Creatinin : 0,6 mg/dl

SGOT/SGPT : 12/11 u/l


Thorax X-ray
BNO X - Ray
BNO X-Ray
WORKING DIAGNOSIS : Intestinal obstruction e.c suspicous volvulus
SIRS

MANAGEMENT : IVFD
Apply NGT
Apply Foley Catheter urine
Medicaments
Report to Senior Digestive Surgeon
advice : Immediate Laparotomy
OPERATION PROCEDURE
Patient laid supine under GA
Disinfection and drapping procedure
Performed midline deepen layer by layer, until
peritoneum
Identify, seen dilatation on every part of the bowel
Seen volvulus ileum and multiple band, 50cm on distal
part and 90 cm proximal part from the ileocaecal valve
Seen ischemic part of the ileum, resection of the ileum is
performed
Decompression of the of the dilatated ileum
Perform end-to-end anostomosis
Control the bleeding and rinse cavum abdomen
Close wound layer by layer with 1 drain
Done
POST OP DIAGNOSIS : Intestinal obstruction e.c volvulus
multiple band
SIRS
PROGNOSIS : Good

FOLLOW UP : Vital Sign


Abdominal Pain