CASE REPORT

Friday,August 1st 2014

Team on duty :
dr. Maria Meildi
dr. Nazir Tambunan
dr. Munawar
dr. Aa Ahmad Dimyati
dr. Raja Raharja M Purba
dr. Sumrahadi Manurung
dr. Yoki Oktadi
dr. Arfan Afandi
I. Patient identity
Name
Age
Sex
Address
Body weight
CM
Fathers phone
Patient came at

: Muhammad Al Ayyubi
: 5 month
: boy
: Abeuk rayek bireun
: 5,1 kg
: 1012457
: 085372649188
: 00.05 WIB

II.

Chief Complaint :
Distension

III.

Present illness history :

The patient referred from district hospital bireun to Zainoel Abidin Emergency
Room with a chief complaint distention since 2 days ago. According to the mother
explanation, the patient always crying intermittenly, he feels the baby quite
discomfort. History of periodic abdominal pain (+). The babys stool was reddish.
History of vomiting (+) greenish. Baby was born by midwife, weight 3200 gram.
History of ANC with midwife.

IV.

Physical examination
Suckling Reflex : (+)
Grasping Reflex : (+)
Crying
: (+)
General appearance
: Moderate
Pulse
: 152 beats/min
Respiratory rates : 46 breaths/min
Body temperature : 38,2 oC
L/S at abdominal region
I: Symmetrical, distention (+), bowel contour (+),
darm steifung (+)
A: Bowel sound (+) decrease
P: Banana sign (+), mass palpable at
the right lower abdominal quadrant.
P: Tymphani (+)

Digital Rectal Examination :

Tonus Sphincter ani was tight
Recti Ampulla was empty
Recti mucose : smooth
Pseudo portio (-)
Glove : current jelly stool (+)
V.
VI.

VII.

Assessment
Total mechanical bowel obstruction due to susp. Intussusceptions
Management
Stop oral intake
OGT
IVFD RL : 5,1 kg x 100 cc = 510 cc/24 hours
Resuscitation Dehydration : 20 cc/KgBB/Hours
5,1 x 20 cc = 102 cc/hours
Urinary Catether : Initial urine 5 cc
Cefotaxime 100 mg
Metamizole sodium 100 mg
Laboratory examination
Radiology examination
Hour

HR

RR

Urin Output

24.00
01.00
02.00
03.00
04.00
05.00
06.00
07.00
08.00
09.00

145
144
144
143
145
142
145
143
146
143

40
42
42
42
40
41
42
41
41
45

5 cc
5 cc
5 cc
7 cc
9 cc
5 cc
4 cc
4 cc
4 cc
5 cc

Laboratory result
Hb
: 9,7 g/dl tranfusion
WBC
: 9.300 /ul
Platelet
: 468.000 /ul
Ht
: 29 %
CT
: 8 minute
BT
: 2 minute
Sodium
: 138 meq/L
Potassium : 4,7 mmol/L
Chloride
: 109 meq/L
Glucose ad random : 67 mg/dL (correction112 mg/dL)
Ureum
: 51 mg/dL
Creatinin
: 0,6 mg/dL
2

VIII

Radiology result :
Ro Baby gram/lateral
Bowel gas distribution not until distal
Dilatation of bowel (+)
USG Abdomen
Doughnut sign (+)

IX.

Diagnose
Total mechanical bowel obstruction due to suspect. Intussusception

X.

Consult to pediatric surgery division :

Laparotomy exploration emergency

XI.

Operative report
Patient was supine position with general anesthesia.
A and anti septic procedure.
Perfomed supra umbilical transverse incision deeper until peritonium
When peritonium is opened, came out clear liquid 50cc
Found dilatation of small bowel ileum dilatation
Indentification from lig Treizt to distal there was intussusception at the
ileocolica until colon tranversum
Perfomed manual reduction (milking procedure) it was release
There was multiple laceration at ileum and the was haemangioma at 25 cm
from ICJ
Decided for resection about 10 cm from proximal ICJ and performed
ileostomy
Bleeding control
Abdominal cavity rinse with warm normal saline until clear
Closure the wound with primary suture

XII.

Post Operative Diagnose

1. Total Mechanical bowel obstruction due to intussusceptions ileocolica
(ICD10 CM K56.1)

XIII. Follow up
Date
S
5/08/
2014
POD
II

Distension HR : 130 beat/minute

1.
Total
(-)
RR : 40 beat /minute
Mechanical bowel
Temp : 36,5oc
obstruction due to
L/S a.r. abdomen
intussusceptions
I : Distention (-), production of
ileocolica (ICD10
stoma (+)
CM K56.1)
A : Bowel sound (+) decrease
P : Pain (+)
P : Thympani (+)

P
Stop oral intake
NGT
IVFD 4:1 510cc/24
hr
Inj.Cefotaxime 150
mg/12 hour
Inj.Metamizol
sodium 150 mg/8
hour

Urine : 5 cc/hours
3