PARALYTIC ILEUS

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PARALYTIC ILEUS Case Report dr. Arief Gunawan, Sp.PD :

PARALYTIC ILEUS Case Report dr. Arief Gunawan, Sp.PD Renita Ramadhany 030.07.213 KOAS INTERNA

IDENTITY :

IDENTITY Name : Mr. M Age : 55 years old Sex : male Education : elementary school Occupation : farmer Religion : Islam Marital status : Married Admitted : May 21th 2012 Taken from : Teluk jambe

Picture of the patient :

Picture of the patient

Anamnese :

Anamnese

History of Present Disease:

History of Present Disease 5 Days before commotion, patient said that his stomach feels bloating. Patient feel his stomach filled up and tense. He didn’t feel his stomach bigger. He didn’t feel any nausea nor throwing up. He still flatus and defecate, but his defecate getting harder and only a little of feses that he defecate, and also constipate. He experienced the abdominal pain and intermittent. Patient experienced the abdominal discomfort in every regio in his stomach. He didn’t feel any fever, and he didn’t experienced pain nor bloody in his urine. 3 days before commotion, his stomach getting bigger and getting more filled up. He still experience the abdominal discomfort. He ’s f eeling nausea and throwing up for three time s , the contents of the puke is water and food that he eat and the volume is about half of the glass of aqua. He felt that he was getting harder to flatus and also for defecate even in one week later o n ly defecate 1 time. He didn’t experience any fever. His urine is in normal line with a yellow colour, there are no pain nor blood. After having the nausea and puking experience, he feel lost of his appetite. 1 day before commotion, patient feel limping. His stomach getting bigger and bigger and also more tense. Patient said that he not defecate yet and also getting harder for flatus. He still experience the nausea. And for the puking experience, it stop 4 days ago but it happens again about 2 time s /day, the content is water about half of a glass. He experience lost of his appetite. There is no complaints about hi s urine. There is no fever. Patient still experience the abdominal pain, and because the abdominal pain is getting severe and the stomach also getting bigger, the defecation getting harder, patient decided to coming to the hospital.

HISTORY OF PAST ILLNESS:

HISTORY OF PAST ILLNESS

Habits History :

Habits History Alcohol consumption (-) Smoking ( + ) Routine Excercise (-) T attoos (-) Blood Transfusion (-) Injected drugs (-) Traditional beverages ( + )

PowerPoint Presentation:

General Condition

Physical Examination :

Physical Examination

Lung examination :

Lung examination Inspection : Sym m etrical , supraclavicula retraction(-), intercostalis retraction(-) Palpation : Equal vocal fremitus Percussion : Sonor in both lung Auscultation : Vesicular breath sound in both lung, Wh -/-, Rh -/-

Heart examination :

Heart examination Inspection : Ictus Cordis is visible at 6 th ICS LMCS Palpation : Ictus Cordis is palpable at 6 th ICS 2 cm medial LMCS Percussion : right-5 th ICS LSD left-at 6 th ICS 2cm medial LMCS upper-at 3 rd ICS LPSS Auscultation : Regular I – II Heart Sound, Murmur ( - ), Gallop (-)

ABDOMINAL EXAMINATION:

ABDOMINAL EXAMINATION Inspection : distended, tense, there is no scar, symmetrical, smiling umbilicus none, no dilated veins Palpation : hard consistency, abdominal tenderness (+), Murphy's sign (-), release off (-), Shifting dullness (-) Liver : no palpable enlarged, there was no tenderness in the liver Spleen : no palpable enlarged Kidney : not found ballotement , CVA (-) Percussion : hypertympani Auscultation : decreased bowel sounds

Extremity Examination:

Extremity Examination Warm acrals Oedema - - - - - - - -

LABORATORY FINDING may , 21, 2012 :

LABORATORY FINDING may , 21, 2012 Blood Results Normal Hb 1 4 .3 12-14 g/dl Ht 43 37-43 % Tromb ocyte 150.000 150.000-450.000 Leu cocyte 12.800 5000-10.000 GDS 1 33 80-140 mg/dl Ureum 36,5 10-45 mg/dl Differential Counting Basophyl 0 0-1% Eosinophyl 0 1-3% Batang 0 2-6% Segment 79 40-70% Lymphocyte 15 20-40% Monocyte 6 2-8%

DIFFERENTIAL DIAGNOSIS:

DIFFERENTIAL DIAGNOSIS

WORKING DIAGNOSIS:

WORKING DIAGNOSIS PARALYTIC ILEUS with HYPERTENSION stage II

SUGGESTED EXAMINATION:

SUGGESTED EXAMINATION

TREATMENT:

TREATMENT

PROGNOSIS:

PROGNOSIS