CASE REPORT
HEMORRHOIDS
Compiled
by::
PRECEPTOR
Adhe
Pusparani
2012
1040 1011
047
DR. DR.
BAMBANG
ARIANTO
SP.B
FINACS
Ade Rahmah 2013 1040 1011 121
PATIENT IDENTITY
Name : Mrs. Maryati
Age
: 44 Years Old
Address: Rungkut Lor X/76 Surabaya
Job: Cigarette factory workers
Last education
: Junior High School
Hospitalize : 12th February 2014, 10.54 AM
Registry number : 679615
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 : GCS : 456
Round pupil isokor 3mm/3mm
Exposure : (-)
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 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 (13 th
February 2014).
HISTORY OF PAST ILLNESS: (-)
SOCIAL HISTORY : Rarely eat vegetables
and drink water, frequent constipation.
ALLERGIES HISTORY : Denied
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 (-)
P
: Movement of the chestwalls symmetric, Krepitasi
(-),deviated
trachea (-), widened intercostals
space (-)
P
: Resonant/ resonant
A : Vesicular +/+, Ronkhi -/-, Wheezing -/-
COR
I : Ictus does not seem
P : Ictus no palpable, thrill (-)
P : heart border normal
A : S1S2 single, Gallop (-), Murmur (-)
Abdomen
I : Flat simetris
P : Soepel , tenderness (-), H/L/R no
palpable,
P : Tympani (+)
A : bowel sounds (+) normal
Ekstremitas
+
Warm acral +
Oedema
Cyanosis
CRT < 2 detik
LOCALIST STATUS
Regio rectum
I : Mass (+), redness (-), swelling (-),
blood (-), prolaps (+)
P : Tenderness (-), can not entered
manually.
Rectal toucher: Anal sphincter normal,
slippery mucosal, pain at 7,11,15, feses
(+), blood (-)
DIAGNOSIS
Internal Hemorrhoids Grade IV
PLANNING DIAGNOSIS: Thorax photo PA
Complete laboratory analysis for pre
operation: DL, UL SGOT, SGPT, BUN, SC,
GDA.
PLANNING THERAPY
Pro hemorrhoidectomy
Infusion RL 1700 cc/24 hours
Terfacef 2x1 gr drip.
Fasting
PLANNING MONITORING
General state
Vital sign.
Patient complaints.
DAILY SOAP
Date
Subjective
Objective
Assesment
Planning
12/2/14
Patiens
present with
bloody bowel
since
approximately
15 years ago,
dripping blood
when
defecating
this day of
fasting pre-op
Nausea (-),
vomiting (-),
no other
complaints
pain while
defecate
urination:
normal
General state:
enough
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 (-)
Internal
Hemorrhoids
gr. IV
(Pro
Hemorrhoidect
omy 13/02/14)
Planning
diagnosis:
Planning
therapy:
Infusion RL
1700 cc/24
jam
Fasting 6
hours
Pre
operation:
Injection
Terfacef 2x1
gr drip PZ
100cc
Planning
monitoring :
General state
Vital sign
Complaints
Daily
SOAP
, H/L/R no
palpable,
tympani,
bowel
sounds (+)
N
Ext: normal
Status
Localist:
Regio
Rectum
I : Mass (+),
redness (-),
swelling (-),
prolapsed
(+)
P : Can not
entered
manually
RT: Anal
sphincter
normal,
slippery
Date
Subjective
-No other
13/2/14 Complaint
-Fasting
since 03.00
p.m
Objective
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
Abdomen:
flat, soepel,
tenderness (-)
Assesment
Planning
Internal
Hemorrhoid
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
Extrimity:
normal
Localys
status :
Status
Localist:
Regio
Rectum
I : Mass
(+),
redness
(+),
swellin
g (-),
prolaps
ed (+)
P : Can
not
entered
manuall
y
Date
14/2/14
Subjective
Recti feels
burn n pain
Not
defecate
today
Urination:
Catheterized
13.00-5.45
1000cc
Nausea (-),
Vomitt (-),
headache (-)
Objective
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, soepel,
tenderness (-)
Tympani
Bowel sounds (+)
N
Extrimity: normal
Assesment
Internal
Hemorrhoid
gr. IV
(1st day post
op.
Hemorrhoide
ctomy)
Planning
Planning
diagnosis:
Planning
therapy:
-Eat and drink
freely
-Bed rest
-Infusion
Futrolit
1500cc/24hrs
-Sanmol 3x1gr
drip
-Merosan 2x1
gr drip PZ
100cc
Planning
monitoring :
General state
Vital sign
Complaints
Urination
Localys
status :
Regio
Perianal
I: mass
(-),
swelling
(-),
Bleeding
(-),
Tampon
(+)
P:
tenderness
(+)
Date
15/2/14
Subjective
Recti
feels burn
and pain,
increased
pain
Tampon
have
been
removed
Flatulenc
e often
accompan
ied by
liquid
defecatio
n , been
drinking
Entrostop
once
time,bloo
d (-)
Urination
:
Catheteriz
Objective
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
Tho:
C/p normally
Abdomen:
flat, soepel,
tenderness (-)
Assesment
Internal
Hemorrhoid
gr. IV
(2nd day
post op.
Hemorrhoid
ectomy)
Planning
Outpatient:
Mobilization
-Infusion
Futrolit
1500cc/24hr
s
Mobillization
-Sanmol
3x1gr drip
-Merosan
2x1 gr drip
PZ 100cc
- Out of
hospital
- Nausea
(+),
decrease
appetite,
insomnia.
tympani
Bowel
sounds (+)
increased
Ext:
normally
Localys
status :
Regio
Perianal
I:
hiperemi
(-),
swelling
(-),
Bleeding
(-),
Tampon (-)
P:
tenderness
(+)
