MORNING REPORT

IDENTITY

Name : Mrs. L
Age : 35 years old
Sex : female
Address : R. Soeprapto
Work : government employees
Doctor in charge : dr. Tedjo Arianto, Sp.B-KBD
Admission : September, 26 2018
Chief complain : pain in the anal canal
Anamnesis :
New patients enter with complaints of anal canal pain since approximately 4 hours ago
before entering the hospital. Other complaints like Nausea (+), gag (-), headache (-), fever (-).
Abdominal pain (-), Defecation and urination is normal, a history of fresh blood coming out when
defecating 1 day ago. History of gallstone surgery 2 years ago and saesaria surgery 8 years ago.
History of the same complaint before : (+) 8 yers ago
History of some disease in the family (-)
History of other diseases (-).
History of medication (+) ardium medicine
History of constipation denied by the patient
PHYSICAL EXAMINATION

General state :
Being sick, good nutrition, composmentis
Vital sign :
BP = 100/70 mmHg
HR = 78x/m, regular, strong
RR = 18x/m, regular
Temperature = 36.7oC
 STATUS PRESENT

Head : Within Normal Limit

Face : Abnormality
Eye : Within Normal Limit
Nose : Within Normal Limit
Ear : Within Normal Limit
Neck : Within Normal Limit
Chest : Within Normal Limit
Abdomen : localized state
Extremity
Superior : Within Normal Limit
Inferior : Within Normal Limit
 LOCALIZED STATE

ABDOMEN
I : convex, join the breath motion
A : peristaltic (+) normal
P : Tenderness (-) , mass (-)
P : thympani (+)

ANAL RECTAL TOUCHER

I : looks mass of the size of Spincter : strangle
zalacca seeds Mucosa : slippery
P : tenderness (+) Ampulla : filled with feces
Handscoen : feses (+) dysentery (-)
CLINICAL FINDINGS
CLINICAL FINDINGS
CLINICAL FINDINGS
 PLANNING

• Routine Blood
 Laboratory Findings

• WBC : 10.17+ • GDS : 80

• HB : 12.3
• PLT : 379 • Bleeding time : 2’05 ≤ 3 menit
• NEUTH: 5.47* • Clothing time : 6’15 6-12 menit
Routine Blood (26/9/2018) • Hbs-

Routine Blood (26/09/2018) Blood chemistry (26/9/2018)

 DIAGNOSIS

External hemorrhoids
Management
Pharmacology
• IVFD RL
• H2RA (ranitidin)
• Analgetic inj. (ketorolac)

Non-Pharmacology
• Education
Consult to digestive surgery
 Thank You

BAGIAN ILMU
BEDAH