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  • Mr. S, Hemorrhoid Internal Gr. IV

    Transféré par

    Umi Kalsum
    25 vues9 pages
    Mr. S, a 52-year-old male entrepreneur, was admitted to the hospital complaining of a painful lump on his anus that had been present for 7 years but recently could no longer be pushed back in. On examination, doctors found a 3cm pink, tender, spongy lump on his anal region. His blood tests and vital signs were normal. He was diagnosed with a grade IV hemorrhoid. He was given analgesic and H2RA medications and referred for consultation with digestive surgery.

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    hemoroid

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    Mr. S, a 52-year-old male entrepreneur, was admitted to the hospital complaining of a painful lump on his anus that had been present for 7 years but recently could no longer be pushed back in. On examination, doctors found a 3cm pink, tender, spongy lump on his anal region. His blood tests and vital signs were normal. He was diagnosed with a grade IV hemorrhoid. He was given analgesic and H2RA medications and referred for consultation with digestive surgery.

    Droits d'auteur :

    © All Rights Reserved
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    Signaler comme contenu inapproprié
    25 vues9 pages

    Mr. S, Hemorrhoid Internal Gr. IV

    Transféré par

    Umi Kalsum
    Mr. S, a 52-year-old male entrepreneur, was admitted to the hospital complaining of a painful lump on his anus that had been present for 7 years but recently could no longer be pushed back in. On examination, doctors found a 3cm pink, tender, spongy lump on his anal region. His blood tests and vital signs were normal. He was diagnosed with a grade IV hemorrhoid. He was given analgesic and H2RA medications and referred for consultation with digestive surgery.

    Droits d'auteur :

    © All Rights Reserved
    Téléchargez comme PPTX, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    sur 9

    Name : Mr.

    S
    Age : 52 years old
    Sex : Male
    Occupation : enterpreneur
    Address : Konawe
    Admission : 19th june 2018
    Doctor in charge : dr. Ld. Rabiul Awal, Sp.B-KBD
    History Taking
     Main complain :
    Lump on the anus
     Anamnesis :
    Patient came to the hospital with complaint of lump on the anus since about 7 years ago.
    Previously that lump could get back into the anus, but couldn’t get back since 3 days
    ago. The lump was painful. There was no fever, nausea and vomit. The urinate and
    defecate was normally.
    There was history fresh blood drops on feces.
    There was no history of other disease.
    There was no history of medicine.
    Generalized State

    General Condition : Moderate illness Head : Within Normal Limit


    Face : Within Normal Limit
    Conciousness : Composmentis, Eye : Within Normal Limit
    Nose : Within Normal Limit
    Vital Sign :
    Mouth : Within Normal Limit
    BP : 120/80 mmHg Ear : Within Normal Limit
    Neck : Within Normal Limit
    RR : 20 x/m Chest : Within Normal Limit
    Abdomen : Within Normal Limit
    HR : 72 x/m
    Upper and lower limb : Within Normal Limit
    T : 36,8 0c Anal Region : localized stated
    ANAL REGIO RECTAL TOUCHER

    • Inspection : Lump (+) • Difficult to evaluate


    Ø 3 cm, the colour due to lump and pain
    was pink

    • Palpation :
    Tenderness (+)
    spongy consistency
    Complete
    blood count
    LABORATORIUM
    FINDING
    Chemistry Blood Test 28/1/2018
    Rontin Blood 28/1/2018
    Parameter result Unit Referen
    Parameter result Unit Referen ce value
    ce value GDS 80 Mg/dl 70-180
    WBC 6,55 10^3/uL 4.00-
    UREUM 29 Mg/dl L=19-44
    10.00

    HGB 15,1 g/dL 12-16 CREATINI 0,6 Mg/dl L=07-


    N 1,2
    PLT 282 10^3/uL 150-400 SGOT 21 U/L L=45

    SGPT 18 U/L L=31


    Hemorrhoid
    DIAGNOSE
    Grade IV
    IVFD

    Analgetic

    H2RA

    Consult
    Digestive
    Surgery

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