HEMORRHOIDS CASE REPORT 201

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CASE REPORT
Preceptor : dr. Bambang Arianto, Sp.B FINACS
A. PATIENT IDENTITY
Name
Age
Address
Job
Last education
Hospitalize
Registry number

: Mrs. Maryati
: 44 Years Old
: Rungkut Lor X/76 Surabaya
: Cigarette factory workers
: Junior High School
: 12th February 2014, 10.54 AM
: 679615

B. SUBJECTIVE
PRIMARY SURVEY
Airway :
Corpus alenium (-)
Maksilofacial trauma (-)
Additional bresth sounds (-)
Gaps (-)
Breathing :

I : Normochest, symmetric, retraction (-), RR: 20x/minute

P: Movement of the chestwalls symmetric, Krepitasi (-),
Trachea deviasi (-), ICS widen (-)
P : Resonant/ resonant
A : Vesicular +/+, Ronkhi -/-, Whizing -/-

Circulatiom : HR : 84x/mnt
Blood pressure : 110/80mmHg
Warm akral (+,+,+,+)
CRT < 2 detik
Disability :
Exposure :

GCS : 456
Round pupil isokor 3mm/3mm
(-)

SECONDARY SURVEY
Main complaint :
Bloody bowel
HISTORY OF PRESENT ILLNESS :
Patiens present with bloody bowel since approximately 15 years ago,
dripping blood when defecating, pain when defecating. Patients work
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in cigarette factory on production, patients always sit during work 8
hours a day during 25 years. Initially, just dripping blood, over time
there is a bulge out of the anus. The bulge can be put back on the
fingers, but lately bulge can not be entered manually. Bowel patients
during this harsh and frequent straining when defecating. Nausea (-),
vomiting (-), no other complaints, eat and drink like. Patient was came
to the general surgery department two days ago and was advised for

get operation at Thursday (13th February 2014).

HISTORY OF PAST ILLNESS: (-)
SOCIAL HISTORY : Rarely eat vegetables and drink water, frequent

constipation.
ALLERGIES HISTORY : Denied
C. GENERAL STATUS :
General state : Good
Blood pressure :110/80 mmHg
HR
: 84 x/minute
RR
: 20x/ minute
Tax
: 36,5 oC
Head/Neck : A-/I-/C-/DThorak
I

: Normochest, symmetric, retraction (-)

: Movement of the chestwalls symmetric, Krepitasi (-),deviated

trachea (-), widened intercostals space (-)

: Resonant/ resonant

: Vesicular +/+, Ronkhi -/-, Wheezing -/-

: Ictus does not seem

: Ictus no palpable, thrill (-)

: heart border normal

: S1S2 single, Gallop (-), Murmur (-)

COR

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Abdomen
I

: Flat simetris

: Soepel , tenderness (-), H/L/R no palpable,

: Tympani (+)

: bowel sounds (+) normal

Ekstremitas

o Warm akral
+
+
o Oedema

+
+

o Cyanosis

o CRT < 2 dtk

D. LOCALIST STATUS
Regio rectum
o I : Mass (+), redness (-), swelling (-), blood (-), prolaps (+)
o P : Tenderness (-), can not entered manually.
o Rectal toucher: Anal sphincter normal, slippery mucosal, pain at
7,11,15, feses (+), blood (-)
E. DIAGNOSIS
Internal Hemorrhoids Grade IV
F. PLANNING DIAGNOSIS: - Thorax photo PA
- Complete laboratory analysis for pre operation: DL, UL SGOT, SGPT,
BUN, SC, GDA.
G. PLANNING THERAPY
- Pro hemorrhoidectomy
- Infusion RL 1700 cc/24 hours
- Terfacef 2x1 gr drip.
- Fasting
H. PLANNING MONITORING
- General state
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-

Vital sign.
Patient complaints.
DAILY SOAP

Date
12/2/14

Subjective

Objective

Assesment

Planning

Patients
present
with
bloody
bowel
since
approxim
ately 15
years ago,
dripping
blood
when
defecatin
g.
Nausea (-),
vomiting
(-), no
other
complaint
s
Pain while
defecate
Urination
normal

General
state: good

Internal
Hemorrhoi
ds Grade
IV

Planning diagnosis:
-

VS:
Blood pressure :
110/80mmHg
HR:84x/m
RR:20x/m
Tax:36,5C

Head/Neck:
A/I/C/D (-)

Thorax:
cor/pulmo:
normal

Abdomen:flat
, symmetric,
tenderness (-)
, H/L/R no
palpable,
tympani,
bowel sounds
(+) N

Ext: normal

Planning therapy:
Infusion RL
1700 cc/24
hours
Fasting 6 hours
Pre operation:
Injection
Terfacef 2x1gr
iv drip in PZ
100 cc
Planning
monitoring :
General state
Vital sign
Complaints

Status lokalis:
Regio rectum
I: mass (+),
redness (-),
swelling (-),
blood (-),
prolaps (+)
P:
Tenderness
(-), can not
entered
manually,
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13/2/14

No other
complaint
Fasting
since 03.00
p.m

Rectal
toucher: Anal
sphincter
normal,slippe
ry mucosal,
pain at
7,11,15, feses
(+), blood (-).

General state:
enough
Vital Sign:
Blood pressure :
120/80mmHg
HR:80x/m
RR 22x/m
Tax: 36,0 C
Head/Neck:
A/I/C/D Thorax:
Cor/pulmo:
normal

Internal
Hemorroids
Gr. IV (Pro
hemorrhoid
ectomy
today )

Planning diagnosis:
Planning therapy:
Infusion RL
1700 cc/24
hours
Fasting 6 hours
Planning
monitoring :
General state
Vital sign
Complaints

Abdomen:flat ,
symmetric,
tenderness (-) ,
H/L/R no
palpable,
tympani, bowel
sounds (+) N
Tympani
Bowel sounds (+)
N
Extrimity:
normal
Localys status :
Regio rectum:
I: mass (+),
redness (+),
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14/2/14

Recti feels
burn and
pain
Not
defecate
today
Nausea (-),
vomit (-),
headache
(-)
Insomnia
Attached
tampons
Urination:
catheterize
d 13.0005.45 :
1000cc

swelling (-),
blood (-),
prolaps (+)
P:
Tenderness
(-), can not
entered
manually,

General state:
enough
Vital Sign:
Blood pressure :
140/80mmHg
HR:80x/m
RR 20x/m
Tax: 36 C
Head/Neck:
A/I/C/D Thorax:
Cor/pulmo:
normal
Abdomen:flat ,
symmetric,
tenderness (-) ,
H/L/R no
palpable,
tympani, bowel
sounds (+) N
Tympani
Bowel sounds (+)
N

Post
operation
Hemorrhoi
dectomy,
day-1

Planning diagnosis:
Planning therapy:
Eat and drink
freely
Bed rest
Infusion Futrolit
1500 cc/24
hours.
Sanmol 3x1 gr
drip
Merosan 2x1 gr
drip PZ 100cc
Planning
monitoring :
General state
Vital sign
Complaints
Urination
Defecation

Extrimity:
normal
Localys status :
Regio perianal
L: mass (-),
redness (-)
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swelling (-),
bleeding (-)
F: tenderness
(+)

15/2/14

Recti feels
burn and
pain,
increased
pain.
Tampons
have been
removed
Flatulence
often
accompani
ed by
liquid
defecation,
been
dronking
Entrostop
once time.
Nausea
(+),
decrease
appetite,
insomnia.
Urination:
catheterize
d 02.0005.30 :
400cc

General state:
enough
Vital Sign:
Blood pressure :
140/90mmHg
HR:72x/m
RR 21x/m
Tax: 36,2 C
Head/Neck:
A/I/C/D -

Post
operation
Hemorrhoi
dectomy,
day-2

Planning therapy:
Mobilization
Infusion Futrolit
1500 cc/24
hours.
Sanmol 3x1 gr
drip
Merosan 2x1 gr
drip PZ 100cc
Out of hospital

Tho:
C/p normally
Abdomen:flat ,
symmetric,
tenderness (-) ,
H/L/R no
palpable,
tympani, bowel
sounds (+) N
Tympani
Bowel sounds (+)
increased
15x/minute
Ext: normally
Localys status :
Regio perianal
L: mass (-),
redness (-)
swelling (-),
bleeding (-),
tampons (-)
F: tenderness
(+)

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