PARALYTIC ILEUS

IDENTITY Nama : Tn. MUsia : 55 thJantina : Laki-lakiEdukasi : SDPekerjaan : PetaniAgama : IslamStatus : Bernikah

Anamnesis

• Nyeri perut sejak 5 hari yllKeluhan Utama

• Perut membesar dan menjadi tegang

• Sulit BAB dan kentut• mual• muntah• Hilang selera makan

Keluhan tambah

an

Riwayat Penyakit Sekarang

5 HSMRS os merasakan perut kembung dan menjadi tegang. perut membesar (-), mual(-), muntah(-), kentut(+), BAB(+) tapi BAB bertambah sulit dan sedikit. Os mengeluh nyeri yang hilang timbul di semua bagian perut. Demam(-), BAK tak ada keluhan

3 HSMRS, os mengeluh perut membesar dan terasa lebih kembung. Mual(+), muntah(+) 3 kali, hasil muntah kayak air dan makanan yang dimakan dan diminum. Os turut mengeluh lebih sulit untuk BAB dan kentut. Demam(-), BAK tak ada keluhan, hilang selera makan (+).

1 HSMRS os merasakan perut masih membesar dan menjadi lebih tegang. BAB (-) untuk 2 hari dan kentut lebih sulit berbanding dahulu. Mual (+), Muntah (+) 2x/hari. Os datang ke RS untuk dirawat karena pembesaran perut dan kesulitan BAB

Riwayat Penyakit Dahulu

Surgery -

Allergies -

Asthma -

Hypertension +

Diabetes mellitus -

Riwayat Penyakit Keluarga

• Keluhan serupa (-)• Hipertensi (+)• Cardiovascular / pulmonary disease (-)• Asthma / allergic (-)• Diabetes mellitus (-)• Kidney disease (-)

Faktor Sosial Pengambilan alkohol (-) Merokok (+) olahraga (-)Tatu (-) transfusi darah (-) suntikan dadah (-) puyer (+)

• Compos mentis• Baik

Keadaan Umum

VITAL SIGN

Blood Pressure:160/100 mmHg

Heart Rate:100 x/mins

reguler

Temperature:

36.8°C

Respiration Rate:

28 x/mins

Pemeriksaan Fizik

• Mesocephal Kepal

a• CA -/-, • SI -/-Mata

• Bibir: cyanosis(-)Mulut

• Lnn. ttbLeher

Pemeriksaan Paru-paru

• Inspeksi : Symmetrical, supraclavicula retraction(-), intercostalis retraction(-)

• Palpasi : Equal vocal fremitus

• Perkusi : Sonor in both lung

• Auskultasi :Vesicular breath sound in both lung, Wh -/-, Rh -/-

Pemeriksaan Jantung

Inspeksi : Ictus Cordis is visible at 6th ICS LMCS

Palpasi : Ictus Cordis is palpable at 6th ICS 2 cm medial LMCS

Perkusi : right-5th ICS LSD left-at 6th ICS 2cm medial LMCS upper-at 3rd ICS LPSS

Auskultasi: Regular I – II Heart Sound, Murmur (-), Gallop (-)

Pemeriksaan Abdomen Inspeksi : distended, tegang, scar (-),

dilatasi vena (-)Palpasi : keras, abdominal tenderness

(+), Murphy's sign (-), rebound tenderness (-), Shifting dullness (-)Hepar : dbnSpleen : dbnKidney : dbn

Perkusi : hypertympaniAuskultasi : BU menurun

Pemeriksaan Extremitas

Akral hangat, WPK < 2 detik

Oedema - -- -

LABORATORY

Blood Results Normal

Hb 14.3 12-14 g/dl

Ht 43 37-43 %

Trombocyte 150.000 150.000-450.000

Leucocyte 12.800 5000-10.000

GDS 133 80-140 mg/dl

Ureum 36,5 10-45 mg/dl

Differential Counting

Basophyl 0 0-1%

Eosinophyl 0 1-3%

Batang 0 2-6%

Segment 79 40-70%

Lymphocyte 15 20-40%

Monocyte 6 2-8%

Paralytic Ileus Definisi: Obstruction of the intestine due to paralysis

of the intestinal muscles. The paralysis does not need to be complete to cause ileus, but the intestinal muscles must be so inactive that it prevents the passage of food and leads to a functional blockage of the intestine. Ileus commonly follows some types of surgery, especially abdominal surgery. It also can result from certain drugs, spinal injuries, inflammation anywhere within the abdomen that touches the intestines, and diseases of the intestinal muscles themselves. Irrespective of the cause, ileus causes constipation, abdominal distention, and nausea and vomiting. On listening to the abdomen with a stethoscope, few or no bowel sounds are heard (because the bowel is inactive). Also called paralytic ileus. Also simply called ileus.

Tanda dan Gejala KlinisDistensi Abd tanpa nyeriVomitusKonstipasi AbsolutDurasi (kalo >3-5 hari maka kausa

mekanikal)Bunyi Usus (kalo tiada-paralytic ileus, kalo

bising-mekanikal)Nyeri (positif kalo mekanikal, negatif kalo

paralytic)X-ray (localised loop of distension without

gas shadow-mekanikal, diffuse distension with gas shadows-paralytic)

WORKING DIAGNOSIS

PARALYTIC ILEUS with HYPERTENSION stage II

TREATMENT

Non-medicamentosa

• control of vital signs

• Decompression NGT, DC

• Bed rest and fasting. If the situation is improving, give soft foods

medicamentosa

• IVFD D5% 20 drops/minute

• Ceftriaxone 2gr (i.v)

• Ranitidin 2x1 (i.v)• Omeprazole 1x1

(i.v)• Antasyd syr• HCT 1x1 (p.o)• Captopril 3x12,5

(p.o)• Adalat 2x1 (p.o)