MORNING REPORTS

SURGERY DEPARTMENT

EMERGENCY ROOM
Wahidin Sudirohusodo General Hospital
Makassar
EMERGENCY CASE REPORT

Ambulation : - Patient
Hospitalized : - Patients
Observation : - Patient
Operated : - Patient
Death : - Patient
Total : - Patients
Wahidin Sudirohusodo General Hospital
Makassar
 Name : MA Age : 29 years
RM : DPJP :
e

Chief complain : Abdominal distended

History taking : Suffered since 3 days before admission. Patient cannot
defecate since 5 days ago. There were history of nausea
and vomiting. There was no history of fever. There was no
history of change bowel habit. There was no history of
operation. Prior medical care is from Jeneponto General
Hospital.
Defecation : Last defecation 5 days ago
General Status
Karnovsky 70% / BMI 19,7/ Conscious

Vital Sign
BP : 110/90 mmHg
PR : 90x/mnt, adequate, reguler,
RR : 22x/mnt, symmetric L=R, thoracoabdominal
type
T (Ax) : 36.8°C
 Local Status
Abdomen
I :Distended, darm steifung (-) darm contour (+), color same as
surrounding skin
A : Bowel sounds decreased
P : Defans muscular (-) no palpable mass
P : Hiper tympanic, Tapping pain (-), Liver dullness (-)
 Digital Rectal Examination
Digital rectal examination
• Sphincter tone was tide
• Mucosa was smooth
• Ampulla empty, no palpable mass
Handschoen: blood (-), feces (-), slime (-)
 Clinical diagnosis
• Intestinal Obstruction due to susp of
volvulus
DDx susp band or adhesion
 Laboratory Findings
 Hb : 16,0 gr/dL
 HCT : 44 %
 WBC : 6.300/uL
NEUT 67,1%
LYMPH 20,6%
MONO 4,3%
EO 0,0%
BASO 0,1%
 PLT : 287.000/uL
 PT : 10,0
 INR : 0,96
 APTT : 26,5
 Albumin : 4,1
 Ur : 122 mg/dL
 Cr : 1.3 mg/dL
 GDS : 135 mg/dL
 Natrium : 144 mmol/L
 Kalium : 3,5 mmol/L
 Klorida : 98 mmol/L
BNO 3 Position (Supine)
BNO 3 Position (Erect)
BNO 3 Position (LLD)
Thorax X Ray
WORKING : Total Intestinal Obstruction due to susp
DIAGNOSIS band or adhesion

MANAGEMENT : • Medicaments
• IVFD
• Plan for laparotomy exploration (if needed
colostomy)
 Operation Report
1. Patient in supine position under general anesthesia
2. Disinfection and draping procedure at abdominal area
3. Midline incision 2 finger below processus xyphoideus to symphisis pubis,
deepen by a sharp and blunt mean until peritoneum reached
4. Open peritoneum ascites fluid was seen, yellowish color about 300 cc
5. Identification and exploration to hollow viscus organ, adhesion grade II-
III was seen between caecum, jejunum, ileum, and part of peritoneum,
adhesiolysis was done.
6. Identification of appendic, appendix looks hyperemic and stick to
surrounding tissue, decided to do appendectomy and double ligation
stitch  appendiceal tissue sent to pathology
7. Bleeding control
8. Wash abdominal cavity with NaCl0,9% until clean and given 1 mediclore
9. Stitch operation wound layer by layer
10. End of operation
Intraoperative findings
POST OP : Total intestinal obstruction due to
DIAGNOSIS adhesion grade II-III + appendicitis

PROGNOSIS : Dubia

FOLLOW UP :• Vital Sign

• Wound care
• Acute abdomen
• Drain production
THANK YOU