ILEUS OBSTRUKTIVUS

LAPORAN JAGARABU, 2 JUNI 2014Report of a caseA man, 59 years old came to the surgery emergency unit with chief complaint open wound in his right feet after traffic injury.Primary Survey Airway and C-spine control Talk spontaneous (+) patent airway Snoring (-) Gurgling (-)

Breathing and Ventilation RR 20 x / min Trachea in the middle JVP not O2 Sat: 100%

Circulation and hemorrhage control: Nadi: 80 x / min (contents and enough voltage) Blood Pressure: 120/80 mmHg Bleeding (+) unstable

Disability GCS E4M6V5: 15 Isokhor 3mm pupil, light reflex + / +

Exposure Regio pedis dextra looks deformity of pedis dextra , tissue discontinuities (+), bleeding (+), pulsasi (+)

Provisional diagnosis Open complete fracture Metacarpal II pedis dextra HOI: 20 minutes before admission patient riding a motorcycle. When riding his motorcycle he was crush by car from behind and he fall down with his feet dragged on the street asphalt. Patient using helmet and his head didnt crush to the street.Bleeding (+), by the crashing of the patient admitted to the Hospital.Past Medical History

History of allergy (-)History of hypertension (-) History of DM (-)History of Cardiac disease(-)History of surgery before (-)

Family history of disease : -Socio-Economic Status : Financing use BPJS

Physical Examination:General condition : compos mentisVital Sign : HR : 80 x/mntTemp : 37,3 C (Axiller) RR : 20 x/mnt BW : 66 kgBP : 120/80 mmHg

Head & Neck : Forehead skin turgor normalConjunctiva palpebra was not anemicShrunken eyes -/-Sclera was not ictericLips mucose was dry (-)Chest Heart:I : IC not seen Pa: IC palpated on SIC V, 2 cm medial of LMCS Pe: Normal configuration A: Basic sound clear, no additional sound Lung: I : Symetric on static and dynamic Pa: Tactile fremitus equal on both of hemi thorax Pe: Sonor on all of lungs area A: Vesicular +/+, no additional soundAbdomen : I : Supel, lesion (-), flat Pa: Tenderness (-) and muscle rigidity (-)Pe: tympanic, LD (+), FD (+)N, SD ()A: Bowel Sound (+) N

ExtremitiesSuperior InferiorCyanotic -/- -/-Cold Acral -/- -/-Sensoric +/+ +/+Motoric 555/555 555/555 Capilary refill