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IDENTITY

Name : Mrs. Maga


Age : 66 years old
Sex : Male
Address : Konawe
Admission : July, 1th 1948
DPJP : dr. Tedjo. A., Sp.B-KBD
HISTORY TAKING
Chief complain :
Black Stool Mixed with blood
Anamnesis :
Patients referrals from Konawe hospital complaining Black stool mixed
with blood since 5 month ago. Nausea (-), Vomiting (-), Stomatch
Bloated (+), urination normally, History of the disease (+) Joint Pain,
History of drug consumption (+) analgetic since 4 years.
State Present
Blood pressure: 150/90 mmhg
Pulse: 88 x/minutes
Breath: 22 x/Minutes
Temperature: 37 ,0 celcius
STATE GENERAL

Head : Normally
Nose : Normally
Mouth : Normally
Ears : Normally
Neck : Normally
Thoraks : Normally
Upper & Lower Extremitas : Normally
STATE LOCALIZED

Abdomen

a. Inspection: Distended (-), Following Breath Motion.


b. Auscultation: Bowel movement increases.
c. Palpation: Tenderness (-)
d. Percussion: Tympani, Liver Deaf (+), Difficult
palpable mass.
Rectal Touched

1. Spincter Ani: Strangle (+)


2. Mucosa: Slippy
3. Ampula: Mass direction clock 12 & 3 size 6 cm
4. Release: Mucus and blood
Plan of Diagnostic

Complete Blood Count


USG transanal
Biopsi
Diagnosis

Tumor Recti DD Ca Recti


MANAGEMENT
IVFD
H2Receptors
Unbleeding
Thank You

BAGIAN ILMU
BEDAH
Erlanza Edisahputra, S.Ked