CASE REPORT

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

Erlina Krisdianita N. (2013 2040 1011 128)

Lecturer :
dr. Bambang Arianto, Sp.B, FINACS

A. IDENTITY
Name : Ny. Sulastri
Age : 44 Years Old
Address : Wonokusumo Jaya
XI/12, Surabaya
MRS : 7
th
March 2014
Registry number : 500029

B. SUBJECTIVE

PRIMARY SURVEY
Airway : Additional breath
sounds (-), Gasp (-)
Breathing :
I : Normochest, symmetric,
retraction (-), RR: 32x/minute
P: Movement of the chestwalls
symmetric, Crepitation (-),
Deviation of Trachea (-), Widening
of ICS (-)
P : Resonant/ resonant
A : Vesicular +/+, Ronkhi -/-,
Whizing -/-

PRIMARY SURVEY
Circulation :
HR : 104x/mnt reguler
Blood pressure :
100/70mmHg
Warm akral (-,-,-,-)
CRT < 2 detik
Disability :
GCS : 456
Round pupil isokor
3mm/3mm
Exposure : (-)

1. CHIEF COMPLAINT :
Abdominal pain
2. HISTORY of PRESENT ILLNESS :
Px had an abdominal pain for a week. Firstly, she
felt the pain in the right lower abdomen and it was
intermittent pain. The pain sometimes got worse when
she was doing her activity. Two days later the pain
persist longer and stayed even when she was not doing
her activity. The pain felt in all her abdomen especially
in the upper abdomen. One week before, she had a
fever. The fever got better when she took a medicine
but she forgot the medicine.


2. HISTORY of PRESENT ILLNESS
Px couldnt defecate smoothly for a week.
Initially she could defecate though only a little bit
and the colour depends on the food she ate. Three
days after she couldnt defecate at all. Px also
couldnt fart. Usually she had a normal defecation
everyday and without straining. Then on Thursday
morning she went to the doctor and was prescribed
a suppositorys medicine for her defecation. After
that she could defecate and had a watery
defecation.

2. HISTORY of PRESENT ILLNESS
Px had a pain during urination since two days ago.
Usually she had a normal urination with no straining
and the colour was still clear yellow. Then px
couldnt urinate since one day before.

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

3. HISTORY OF PAST
ILLNESS:
Asthma
Urinary Tract Infection
denied
Bloody defecation
denied
DM denied
HT denied

4. SOCIAL HISTORY :
Px only drinks for about
500 cc of water
everyday
Px likes to eat
vegetable everyday
5. ALLERGIES
HISTORY : Antalgin,
Ponstan, Cold weather

GENERAL STATUS :

General state : unwell

Blood pressure :100/70
mmHg
HR : 104 x/minute
RR : 32x/ minute
Tax : 36
o
C

Head/Neck : A-/I-/C-/D+
enlargement
lymphnode (-)
Thorak
I : Normochest,
symmetric, retraction (-)
P : Movement of the
chestwalls symmetric,
Krepitasi (-), deviated
trachea (-), widened
intercostals space (-)
P : Resonant/ resonant
A : Vesicular +/+, Ronkhi
-/-, Wheezing +/+

COR
I : Ictus does
not seem
P : Ictus does
not palpable, thrill (-)
P : heart
border normal
A : S
1
S
2

single, Gallop (-),
Murmur (-)

Abdomen
I : convex,
darm contour (-), darm
steifung (-), mass (-)
P : defans (-),
H/L/R no palpable, pain in
palpation



P : timpany
A : bowel
sounds (+) 11x/minute

+ + +
+ + +
+ + +
Extremity :
Warm akral



Oedema



Cyanosis




CRT < 2 dtk


- -
- -
- -
- -
- -
- -
LOCALIZED STATUS
RT : couldnt be evaluated. Px refused because
when she has been examined by the doctor on
Thursday morning.
Urology Status
Flank pain : +/-
Flank mass : -/-
Pain in palpation of flank : -/-
Pain in percussion of CVA : +/-
GE : patient was catheterized since Thursday night at
9pm. On Friday evening, the urine was just 100cc.

LABORATORY EXAMINATION
Hb 11,0
Leukocyte 20.190
Thrombocyte 271.000
Hematocrit 32,1
GDA stik 87
BUN 34
Creatinin serum 3,9
SGOT 20
SGPT 19
Potassium 3,0
Natrium 129
Chloride 88
RADIOLOGY - - THORAX PA
RADIOLOGY - - USG
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 of
appendix, free fluid (+), increasing in bowel gas
CONCLUSION : increasing in bowel gas ?, suspect acute
appendicitis, other organ normal

RADIOLOGY - - BOF - LLD
Herring bone sign (+)
Coil spring (+)
Stone in cavum pelvic
No enlargement in hepar and lien
Simetrical psoas shadow
Conclusion : suspect ureterolithiasis 1/3 distal with
partial obstructive of ileus

ASSESSMENT
Suspect Ureterolithiasis 1/3 distal and partial obstructive of
ileus
PLANNING THERAPY
O
2
nassal 2-4 L
Infused RL 20 tpm
NGT 16 Fr
Cateter 16 F two way
Ceftriaxon injection 1 gr
Pro Operation
PLANNING MONITORING
General state
Vital sign.
Patient complaints