19-02-2017

DM. Nurmalinda dan DM. Norman

WHM  Age : 51 years old  Sex : Male  Address : Air nona . IDENTITY   Name : Tn.

Headache (-). defecation (-). he felt abdominal discomfort and pain all over the abds and the pain increasing because cant defecation. Anamnesis   Chief Complaint : Can not defecation  History (autoanamnesis) : Patient come with complaint can’t defecation since 2 days before come to the ED. urinate (+) . vomiting (-). flatus (-). nausea (+).

wheezing (-/-) . ronchie (-/-). Physical exam  Vital sign   BP : 120/70  HR : 92 x/min  RR : 24x/min  T : 37. reguler. gallop (-)  Pulmo : vesicular (+/+). pattern of respiration is abdominothoracal  Cor : s1 s2 single. icteric (-/-)  Thorax : chest expansion bilateral simetric. murmur (-). pupil isokor (+/+).1  Eye : anemic (-/-).

handschoen : mucous . prostat normal. mass (-). tenderness pain (-).   Abdomen  Inspection : distended (+)  Auscultation : peristaltics (+) 3-4x/min  Palpation : tenderness pain (+) all abdomen  Percusion : timpany sound (+)  RT : sphingter normal. ampula recti normal.

4 gr/dL RBC 5.31 x 10^3/uL Plt 303 x 10^3/uL .8 % WBC 13. Laboratorium  CBC : Hb 14.57 x 10^6/uL Ht 39.

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 .