19-02-2017

DM. Nurmalinda dan DM. Norman

 IDENTITY

Name : Tn. WHM
Age : 51 years old
Sex : Male
Address : Air nona
 Anamnesis

Chief Complaint : Can not defecation
History (autoanamnesis) :
Patient come with complaint cant defecation since 2
days before come to the ED, he felt abdominal
discomfort and pain all over the abds and the pain
increasing because cant defecation. Headache (-), nausea
(+), vomiting (-), defecation (-), flatus (-), urinate (+)
 Physical exam
Vital sign

BP : 120/70
HR : 92 x/min
RR : 24x/min
T : 37.1
Eye : anemic (-/-), pupil isokor (+/+), icteric (-/-)
Thorax : chest expansion bilateral simetric, pattern of
respiration is abdominothoracal
Cor : s1 s2 single, reguler, murmur (-), gallop (-)
Pulmo : vesicular (+/+), ronchie (-/-), wheezing (-/-)

Abdomen
Inspection : distended (+)
Auscultation : peristaltics (+) 3-4x/min
Palpation : tenderness pain (+) all abdomen
Percusion : timpany sound (+)

RT : sphingter normal, ampula recti normal, mass (-),

prostat normal, tenderness pain (-), handschoen :
mucous
 Laboratorium

CBC :
Hb 14.4 gr/dL
RBC 5.57 x 10^6/uL
Ht 39.8 %
WBC 13.31 x 10^3/uL
Plt 303 x 10^3/uL
 Planning diagnosis

BNO 3 posisi
 Assessment

Konstipasi
 Planning therapy

IVFD RL 20 tpm
Inj Omeprazole 1 vial/ iv
Dulcolax supp I
Laxadine syr 3xc1
Pasang DC dan NGT
Balance cairan


THANK YOU