Identity

• Name : Mr. I
• Age : 50 years old
• Sex : Male
• Address : Lahindaro
• Admission : November 27th 2018
• DPJP : dr. Laode Rabiul Awal, Sp.B. KBD
 History taking
• Chief complaint : abdominal pain
• Anamnesis :
A patient refered from Buton Hospital with abdominal pain at all of
abdomen region, this was suffred since 6 days ago. The pain felt
continously and his abdomen become bigger and distended. Patient
complain about nausea, vomiting and anorexia too, there was no
history fever. Urination like thick tea, defecation was like “goat feaces”
4 days ago. Last defecation and flatus was 4 days ago.
There was no history of got operated prosedure before, There was no
history of treatment , there was no history of the same complaint
before.
 Physical examination

•The patient was conscious with severe ill

•Blood Pressure 140/80 Mmhg Pulse = 102x/m, reguler, strong
•Respiratory Rate = 22x/m, symmetric, thoracoabdominal type
•Temperature = 36.7oC
 Generalized status

Head : within normal limit

Face : within normal limit
Eyes : conjungtiva anemis (-/-)
Nose : within normal limit
Mouth : within normal limit
Ears : within normal limit
Neck : within normal limit
Chest : within normal limit
Abdomen : Localized State
Extremitas : within normal limit
Genetalia : within normal limit
 Generalized status
• Abdomen • Rectal toucher
I nspection : convex, follow the Sfingter Ani : Strangle
motion breath (+), distended Mucosa : Palpable mass
abdomen (+)
Ampulla : Empty
Auscultation : Peristaltic was
Handscoen : mucus and fresh
increased, metalic sound (+)
blood.
P : Tenderness (+) at all region,
organomegaly (difficult to
assess)
P : Tympanic at area near umbilical,
other was dull
Clinical findings
Abdominal X-ray 3 position

-Dilatasi loop-loop usus yang membentuk

gambaran herring bone serta step ladder
-Tidak tampak udara bebas subdiafragma
-Kesan gambaran ileus obstruksi
Laboratory Findings

• WBC : 8,39(103/uL)
• HB : 10,1 g/dL
• PLT : 368 g/dl
• Ureum : 64
• Creatinine : 0,7
• SGOT : 29
• SGPT : 22
Working diagnosis

Ileus obstruktif
MANAGEMENT
• Stop intake oral
• IVFD
• Antibiotic
• Analgetic
• Consult a Surgeon