Identity

• Name : Mr. N
• Age : 75 years old
• Sex : Male
• Address : Kolaka
• Admission : Dec 27th 2018
• DPJP : dr. Laode Rabiul Awal, Sp.B. KBD
 History taking
• Chief complaint : abdomen pain
• Anamnesis :
A patient refered from Benyamin Hospital with abdominal pain at whole
abdomen region, this was suffred since 4 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 2 days ago.
There was no history of got operated prosedure before, There was
history of treatment from benyamin hospital since 10 days ago , there
was no history of the same complaint before.
 Physical examination

•The patient was conscious with severe ill

•Blood Pressure 140/90 Mmhg Pulse = 98x/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 - Sphincter was less tight,
motion breath (+), distended - mucous layer smooth,
abdomen (+), darm countour (-),
- ampulla : colapse
darm steifung (-)
- Handscoen : blood (-), faeces (-),
• Auscultation : Peristaltic was
mucus (-).
increase, metalic sound (-)
• Palpation : Tenderness (+) at all
region, mass at the lower left
abdomen, organomegaly (difficult to
assess)
• Percution : hypertympanic
Clinical findings
Abdominal X-ray 3 position

-Dilatasi loop-loop usus yang membentuk

gambaran step ladder
-Kesan gambaran ileus obstruksi
Laboratory Findings

• WBC : 10,27(103/uL)
• HB : 12,4 g/dL
• PLT : 246 g/dl
Working diagnosis

Ileus obstruktif ec suspc. Tumor colon

MANAGEMENT
• Stop intake oral
• NGT
• IVFD
• Antibiotic
• Analgetic
• Consult a Surgeon