Genereal Surgery Division

Departement of Surgery
University of Halu Oleo

Ileus Obstructive

Presented by : “General Surgeon Division”

Supervisor : “dr. Syamsul Rizal, Sp. B., M.Kes ”
Emergency Case Report
December 2023
 Patient’s Identity
Name : Mr. M
Age : 48 y.o
Sex : Male
Address : Raha
Religion : Moeslim
Marital status : Married
RM Number : 63 xx xx
Hospitalized : 26 Dec 2023
 Patient History
Chief Complaint:
Abdominal Pain

History Complaint:
Referral patient from Dewi Sartika Hospital with diagnosis Sepsis +
Obstructive Ileus + Post Laparatomy (28th Nov 2023). Initial complaints of
tight stomach for 3 days SMRS accompanied by bloating, no fever, no
nausea and no vomiting. BAK dbn, small bowel movements, Flatus (+).
There is a wound on the surgical suture +/- 1 week Wet (+), smelly (+)
General appearance : Moderate ill
Physical Examination
Consciousness : Compos Mentis (GCS 15,
E4V5M6)
Vital sign :
Blood pressure : 120/83 mmHg
Heart rate : 64 x/minutes
Respiratory rate 21 x/minutes
Temperature 36.7 C
Saturation 97%
VAS : 1/10

Generalization Status
Head: Normochepal
Eyes : Anemic (+), icteric (-), sunset phenomenon (-) pupil isocortical
Nose : Rinorrhea (-), epitaxis (-)
Mouth: stomatitis (-), cyanosis (-),
Neck: KGB enlargement (-),
Thorax: Symmetrical left and right, vesicular breath sounds, wh (-), rh (-)
Abdomen: see Localized Status
Upper extremities: acral warm, CRT < 2 seconds
Lower extremities: acral warm, CRT < 2 seconds
 Physical Examination
Localized Status: Abdominal region
Inspection: flat, follow the movement of
breath
Auscultation: normal peristaltic sound
Palpation: Pain in Epigastric-Umbilicus-
HypogasticPercussion: timpani (+)
 Laboratorium test
Hematology: (26/12/2023)

Item Find Satuan Nilai rujukan

WBC 21.4 10^3/µL 4.6-10.2
RBC 3.84 10^6/µL 4.7-6.1
PLT 191 10^3/µL 130­- 400
HB 9.7 g/dl 14.1-18.1
HCT 27.2 % 43.5-53.7
MCV 78.2 fL 80.0-97.0
MCH 27.9 pg 27.0-31.2
MCHC 35.7 d/dl 31.8-35.4
 Laboratorium test
Count Type
(26/12/2023)
Item Result Units Reference range
Neutrophils 89.7 % 52.0-75.0
Lymphocytes 6.3 % 20-40
Monocytes 3.5 % 2.0-8.0
Eosinophils 0.5 % 1.0-3.0
Basophils 0.0 % 0.-0.10
 Laboratorium test
Clinical Chemistry: (26/12/2023)
Item Find Satuan Nilai rujukan
GDS 98 mg/dl 70 - 180
Ureum 108 mg/dl 15-40
Creatinin 0.9 mg/dl 0.5-1.0
SGOT 61 U/L <31
SGPT 103 U/L <31
 Radiology
BNO 3 Position
(19/12/2023)
 Diagnosis
Working Diagnosis :
Ileus Obstructive
Sepsis
Post Laparatomy
 Planning
― IVFD RL 20 tpm
― Inj. Ketorolac 1 ampule/IV
― Inj. Ranitidine 1 ampule/IV
― Inj. Meropenem 1 gr/IV
 Thank You
For Your Attention