Mechanical bowel obstruction

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Transcript of Mechanical bowel obstruction



Chief Complaint: Can not defecateIt 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.

Present State :Awareness : AlertBlood pressure : 110/70 mmHgHR : 98 x/iRR : 24 X/iTemp : 38,60C

Generalized StateHead 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 hemithoraxAbdomen: Localized stateGenitalia: male, no abnormalityExtremity : no abnormality

Localized state:Abdomen: I : Symmetry, distention (+), visible bowel movement (+) P: Tenderness (+)P: HypertympaniA: peristaltic (+) increase

DRE: perineum usual, tight tonus anal sphincter, pain (-), smooth mucosa, ampulla recti was collaps. Hand gloves : Feces (+), blood (-), mucous (-)

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

Chest X-ray

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

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