Mechanical bowel obstruction, Eko Indra, www.senseheal.blogspot.com

1. AT/M/19yo

2. Chief Complaint : Can not defecate
It has been suffered since 7 days before admitted to
hospital. He also complained of intermittent
abdominal pain. Flatus (+). Patient had fever since
one week before. Vomiting more than 5 times a
day. History of weight loss (+). Cough since a month
ago, with greenish sputum without blood. History
of night sweat (+). Micturition (+) normal. History of
tuberculosis in the family was denied.

3. Present State :
Awareness : Alert
Blood pressure : 110/70 mmHg
HR : 98 x/i
RR : 24 X/i
Temp : 38,60C

4. Generalized State
Head and neck : conj palp inf pale (-)
Thorax : I : simetric
P : SF equal on both hemithorax
P : sonor on both of hemithorax
A : Sound of breath : vesicular on both of hemithorax
Abdomen : Localized state
Genitalia : male, no abnormality
Extremity : no abnormality

5. Localized state:
Abdomen:
I : Symmetry, distention (+), visible bowel movement (+)
P: Tenderness (+)
P: Hypertympani
A: peristaltic (+) increase
DRE: perineum usual, tight tonus anal sphincter, pain (-), smooth
mucosa, ampulla recti was collaps. Hand gloves : Feces (+), blood
(-), mucous (-)

7. Laboratorium finding:
Hb / Hct / WBC / PLT : 13,3/41,7/9,1/331
Na / K / Cl : 145/3,9/104
Albumin : 3,1
Random Blood Sugar Level : 116,0
Ur/Cr : 108,45/2,37

8. Chest X-ray

11. Working Diagnosis :
Partial Mechanical Bowel Obstruction d/t Susp.
Peritoneal TB

12. Management in Emergency Room:
• Nil per mouth
• Insertion NGT,comeout clear fluid about 100 cc
• Insertion urine cateter,came out initial urine
output about 110 cc,clear yellow colour
• IVFD Crystalloid
• Inj. Antibiotics
• Inj.Analgetic
• Conservative
• Plan : CT Scan Abdomen