lapsus ileus obstruksi rhy

8/11/2019 lapsus ileus obstruksi rhy

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CASE REPORTBOWEL OBSTRUCTION

By :Ringenggo H. P. (2013 2040 1011 124)

Erlina Krisdianita N. (2013 2040 1011 128)

Lecturer :

dr. Bambang Arianto, Sp.B, FINACS


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A. IDENTITY

Name : Ny. Sulastri Age : 44 Years Old Address : Wonokusumo Jaya

XI/12, SurabayaMRS : 7 th March 2014Registry number : 500029


3/18

B. SUBJECTIVE

PRIMARY SURVEYAirway : Additional breathsounds (-), Gasp (-)

Breathing :

I : Normochest, symmetric,retraction (-), RR: 32x/minute

P: Movement of the chestwallssymmetric, Crepitation (-),Deviation of Trachea (-), Wideningof ICS (-)

P : Resonant/ resonant A : Vesicular +/+, Ronkhi -/-,Whizing -/-

PRIMARY SURVEYCirculation :HR : 104x/mnt regulerBlood pressure :100/70mmHgWarm akral (-,-,-,-)CRT < 2 detikDisability :

GCS : 456Round pupil isokor3mm/3mmExposure : (-)


4/18

1. CHIEF COMPLAINT : Abdominal pain

2. HISTORY of PRESENT ILLNESS : Px had an abdominal pain for a week. Firstly, shefelt the pain in the right lower abdomen and it wasintermittent pain. The pain sometimes got worse whenshe was doing her activity. Two days later the painpersist longer and stayed even when she was not doingher activity. The pain felt in all her abdomen especiallyin the upper abdomen. One week before, she had afever. The fever got better when she took a medicine

but she forgot the medicine.


5/18

2. HISTORY of PRESENT ILLNESSPx couldnt defecate smoothly for a week.

Initially she could defecate though only a little bitand the colour depends on the food she ate. Threedays after she couldnt defecate at all. Px alsocouldnt fart. Usually she had a normal defecationeveryday and without straining. Then on Thursdaymorning she went to the doctor and was prescribed

a suppositorys medicine for her defecation. Afterthat she could defecate and had a waterydefecation.


6/18

2. HISTORY of PRESENT ILLNESSPx had a pain during urination since two days ago.Usually she had a normal urination with no strainingand the colour was still clear yellow. Then pxcouldnt urinate since one day before.

Px had a decreasing in appetite since she got afever. Px also had a nausea but she didnt vomit.


7/18

3. HISTORY OF PASTILLNESS:

Asthma

Urinary Tract InfectiondeniedBloody defecationdenied

DM deniedHT denied

4. SOCIAL HISTORY :Px only drinks for about500 cc of watereverydayPx likes to eatvegetable everyday

5. ALLERGIESHISTORY : Antalgin,Ponstan, Cold weather


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GENERAL STATUS :

General state : unwell

Blood pressure :100/70mmHgHR : 104 x/minute

RR : 32x/ minuteTax : 36 oC

Head/Neck : A-/I-/C-/ D+ enlargementlymphnode (-)

ThorakI : Normochest,symmetric, retraction (-)P : Movement of thechestwalls symmetric,Krepitasi (-), deviatedtrachea (-), widenedintercostals space (-)P : Resonant/ resonant

A : Vesicular +/+, Ronkhi

-/-, Wheezing +/+


9/18

COR I : Ictus doesnot seem

P : Ictus doesnot palpable, thrill (-) P : heartborder normal

A : S 1S 2 single, Gallop (-),Murmur (-)

Abdomen I : convex,darm contour (-), darmsteifung (-), mass (-)

P : defans (-),H/L/R no palpable, pain inpalpation

P : timpany A : bowelsounds (+) 11x/minute

+ + +

+ + ++ + +


10/18

Extremity :Warm akral

Oedema

Cyanosis

CRT < 2 dtk

- -- -

- -- -

- -

- -


11/18

LOCALIZED STATUS

RT : couldnt be evaluated. Px refused becausewhen she has been examined by the doctor onThursday morning.Urology Status

Flank pain : +/-Flank mass : -/-Pain in palpation of flank : -/- Pain in percussion of CVA : +/-GE : patient was catheterized since Thursday night at9pm. On Friday evening, the urine was just 100cc.


12/18

LABORATORY EXAMINATION

Hb 11,0

Leukocyte 20.190

Thrombocyte 271.000

Hematocrit 32,1

GDA stik 87BUN 34

Creatinin serum 3,9

SGOT 20

SGPT 19Potassium 3,0

Natrium 129

Chloride 88


13/18

RADIOLOGY - - THORAX PA


14/18

RADIOLOGY - - USG


15/18

Liver : normal size, echoparencym intensity homogeneous normal,clear angle, regular edge, porta venous & hepatica venous normal,cyste (-), nodul (-)

Gall Bladder : normal size, stone (-), mass (-)

Pancreas : normal size, echoparencym intensity normal, cyste(-), nodule (-), calcification (-)Lien : normal, normal echoparencym intensity,nodule/cyste/calcification (-)

Ren Dex/Sin : normal size, normal echocortex, stone (-), cyste(-),PCS normal

Bladder : stone (-), mass (-)Uterine : normal. Adnexa : normal

Mc Burney : pain in palpation, looks like an inflammation ofappendix, free fluid (+), increasing in bowel gas

CONCLUSION : increasing in bowel gas ?, suspect acuteappendicitis, other organ normal


16/18

RADIOLOGY - - BOF - LLD


17/18

Herring bone sign (+)Coil spring (+)Stone in cavum pelvic

No enlargement in hepar and lienSimetrical psoas shadowConclusion : suspect ureterolithiasis 1/3 distal withpartial obstructive of ileus


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ASSESSMENTSuspect Ureterolithiasis 1/3 distal and partial obstructive ofileusPLANNING THERAPY

O 2 nassal 2-4 LInfused RL 20 tpmNGT 16 FrCateter 16 F two wayCeftriaxon injection 1 grPro Operation

PLANNING MONITORINGGeneral stateVital sign.Patient complaints

lapsus ileus obstruksi rhy

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