Department of Surgery

Sept 18, 2014

Name : Mrs. E Age : 34 y.o Sex : female Address : solokuro, lamongan Date examination: sept 18, 2014

ANAMNESIS Chief complaint

Abdominal pain

History of Present Illness

patient came with complaint pain at stomach since 3 days ago.

Pain felt suddenly, early abdominal pain feels like heartburn, then

patients do massage. 1 day later the patient felt stomach pain and

the patient becomes unable to stool and flatus. vomiting + 1 day

ago contents of food. Decrease of appetite +. Fever denial, crowded

denied, denied dizziness. Urination within normal limit. Early the

patient didn’t has diarrhea or constipation. History of melena or

vomiting of blood denial.

• History illness Alergy-, DM -, HT -, gastritis +, patients never feel the

same illness before.History of SC 1,5 month ago.History of laparotomy e.c KET 1 years ago.• Family illness :

(-)• Social history : patients never drink herbal or medicinal stiff. patients

regularly eat fruits and vegetables every day. patients defecation 3 day at once

Airway and spine control : clear (+), snorring (-), gargling (-), potensial obstruction (-)

Breathing : spontan, simetric (+), RR 27x/minutes, ves/ves, rh-/-, wh-/-

Circulation : PR 95x/minutes, acral warm dry red, CRT < 2”, BP 157/96

Disability : GCS 456, LP +/+, isocor pupil 3mm/3mm, lateralisasi-

Exposure : temp 37.2 ’C

Head and neck : anemic (-), icteric (-), cyanosis (-), dyspneu (-). Thorax : simetric (-), retraction (-)

Pulmo : ves/ves, rh-/-, wh-/-Cor : S1S2 single, murmur (-), gallop (-)

Abdomen : distended, soefl, met (+), liver and spleen were not palpable, decrease of bowel sound, pekak hepar +, tenderness + et lower quadran. Nyeri ketok kuadran bawah +, blumberg sign +, obturator sign -, psoas sign -

Extremities : acral warm, dry, red. Aie - Rectal touche : TSA : normal. Ampula recti : dbn,

terisi feses, Mukosa rectum : dbn, tidak teraba massa. Nyeri : (-), Cairan bebas di cavum douglasi : (-)

Clue and cue female 34 y.o Abdominal pain Defecation – Flatus – Vomit Decrease of appetIte History of Gastritis distended Meteorismus + Tenderness + lower quadran abd. Blumberg sign + History of SC 1,5 month ago. History of laparotomy e.c KET 1 years ago.

AssesmentAssesment

Ileus obstructif

DD: appendicitis

• CBC• Electrolit serum• BOF• LLD• USG

CBCCBC

Diff 2/2/86/9/1Hct 39.8Hb 13.3Lekosit 11.200Trombosit 297.000GDA 99Kalium serum 3,9Na serum 137Clorida serum 103

BOFBOF

LLDLLD

AssesmentAssesment

Ileus obstructif

DD: appendicitis

• Ivfd asering 1500cc/24jam• Inj ceftriaxone 2x1g• Inj ranitidin 2x1amp• Inj.metronidazol 3x500mg• c/ Sp. B

Subjective complaint Vital sign

Explain to the patient’s family about the diagnosis, etiology, intervention of therapy, complication, and prognosis.