MEDICAL RECORD

Name of patient Nationality D.#. Se' : Mr. Komang Sudarma : Indonesia : $%& years old : male Admission Date : 12/10/2012 Addres : Ds Satra r. Kem!angsari Kintamani" ali

MAIN COMPLAINT & EXPLANATION Main (omplaint : (an)t do regullar !o*el +leansing ,'planation on details : " Sin+e - mont. ago .e .ad pro!lem *it. regullar !o*el +leansing% sometimes for 1'/day% sometimes /ust for 1'/*ee0% it made .im feel un+omforta!le% !ut *it.out any pain or +ramps on stoma+.% no fe1er% no diarr.oea. 2.ile t.at t.e 0ids still .ad a+ti1e mo1ement and normal gro*t. and p.ysi+ology+al de1elopment. " 3e .ad regullar +onsumption *it. ri+e% sometimes *it. mil0 !ut less 1egeta!les and fruit 4t.e 0ids doesn)t *ant it mu+.5% .e *as normal *.en gi1e !irt. as t.e 1st son from t.e parents. 6ast Medi+al 3istory : 4"5 VITAL SIGN & PHYSICAL EXAMINATION lood 6ressure : 100/70 6ulse 8ate : 72' / minute 9emperature : $-%:;( 8espiration : 20' / minute 6.ysi+al ,'amination : " 3ead normal% no anemia% no +yanosis " (.est regullar !reat.ing sounds% no a!normality on lungs and .earts " Stoma+. loo0s solid on +onsisten+y% peristalti+ sound normal " ,'tremity normal PEMERIKSAAN PENUNJANG '"ray on stoma+. 40onstipasi/full of stools on stoma+.5 DIAGNOSE & POSSIBLITIES 2or0ing Diagnosis #t.er 6ossi!ilities 8egular Medi+ation " : Konstipasi : Immature digesti1e en<im on stoma+./!o*el +leansing disorder : Mi+rola' suppositoria 1'/in +ase .ad 0onstipasi

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DOCTOR RECOMMENDATION This is norm ! h ""#n#$ %i&h &h# 'hi!$r#n %h#n &h# $i(#s&i)# #n*im no& !r# $+ ,-- . m &&/r#0 so $o#s m $# "ro1!#m %i&h 1o%#! '!# nsin(2 3h#n h# (#& o!$#r so $o#s &h# #n*im %i!! m &&/r# n$ &h# 1o%#! '!# nsin( %o/!$ 1#'om# r#((/! r /n&i! norm !2 R#(/!! r!+ # & )#(#& 1!#s n$ 4r/i& 4or h#!"in( m#& 1o!ism &o # si#r &o (#& 1o%#! '# nsin(2

Singara/a% 12 #+to!er 2012 Dr. I 2ayan 6arna A