No.

Name : DC Sex : Female

45
Age : No. Reg : 646097
years
Chief complaint : Abdominal Pain

History taking : This condition had been apparent for 2 months before
admitted to ER. The intention of the pain is getting worse in
the last week. History of defecation normal . There are
vomiting 5-6x. Nausea (+)
Micturation : Normally
General Status
Moderate illness / well nourish / conscious

Vital Sign
BP : 150/90 mmHg
PR : 96x/mnt, strong, reguler,
RR : 20x/mnt, symmetric L=R, thoracoabdominal
type.
T(Ax) : 37,1C
 Local Status
Abdominal
I : Convex, follow breath motion, skin color same with its vicinity,
bowel contour (+), bowel motion (+)
A : Peristaltic (+)
P : No palpable mass in every region
P : Tapping pain (+), hyper timpani
 Digital Rectal Examination

Sphincter tone was tight

Mass was palpated with 2x2 cm size with solid
consistency
Ampulla empty
Handscoen : blood (+), feces (-), slime (+)
 Laboratory Result
WBC : 23,9 x 103 / L Natrium : 131 mmol/l

RBC : 5,42x 106 / L Kalium : 5,6 mmol/l

HGB : 11,5 g/dL Clorida : 98 mmol/l

HCT : 36,8%

PLT : 531 x103/ L PT : 17 detik

CT / BT : 700 / 2 00 APTT : 26,0 detik

Blood Sugar : 67 mg/dl Hbs Ag : Negatif

Ureum : 58 mg/dl

Creatinin : 0,9 mg/dl

GOT / GPT : 30/13 /L

Abdominal USG
BNO
WORKING DIAGNOSIS : Ileus obstruction

MANAGEMENT : Oxigenation
IVFD
NGT
Urine Catheter
Medicaments
Report to senior digestive surgeon
advice : laparotomy exploration
 Operating Procedure
Patient laid in supine position under GA.
Sterilization and draping procedure
Incision 2 finger under umbilical right side, deepen until
peritoneum
Open peritoneum seen invagination of ileum +
terminal ileum + colon acendens+ colon ( ileo coli colica)
Released with milking procedure clean with NaCL 0,9
% seen intestine viable
Fixation ileum with colon acendens
Clean with NACL 0,9%
Close operating wound layer by layer
Operation finished
POST OP DIAGNOSIS : Ileus obstruction ec ileo colicolica
invagination

PROGNOSIS : Good
FOLLOW UP : Vital sign and wound healing