IDENTITY

Name
: Mrs. Wa Inu
Age
: 61 years old
Sex
: female
DPJP
: dr. H. Syamsul Rijal,
Sp.B
Admission
: September, 23th
2016

Main complain : Pain at lower abdomen

HISTORY
TAKING
Anamnesis : A Reference from Raha
Hospital. Patient complained
an
abdominal pain at lower abdomen,
continously along this couple weeks.
Other complainment are dizziness, no
fever, nausea and vomiting a day
before admitted.
There was a previous medication in
Raha Hospital caused difficulty of
urination with a backish defecation
history.
History of ultrasound with the results

GENERAL STATE
Head :
General State :
Composmentis,
Vital Sign :
BP: 110/60 mmHg
RR

: 32x/m

Normal
Face: Normal
Eye : Normal
Nose

Normal

HR : 88x/m

Ear : Normal

Neck

: 36,50c

Normal

General
state
Head: Normal
Face : Normal
Eyes : Normal
Nose : Normal
Mouth: Normal
Ears : Normal
Neck : Normal
Chest : Normal
Extremity
Upper : sindaktil finger (d/s)
Lower : piting edema (+)(s) and

LOCAL STATE
ABDOMEN
INS : Flat, follow the motion,
distended (-)
AUS : Peristaltic was increased
impression.
PER : Deaf To The Entere Abdomen
PAL : There a mass on hypogastric
regio, with a smooth surface and
hard consistency. Tenderness to
regio inguinalis and regio iliaka
sinistra,

Rectal Toucher:

Weakened sphincter ani

Ampula recti was not
collapse Containing
Feces
There is tendderness
Feces Extrication

Laboratory

Laboratory

RADIOLOGY FINDING

USG

-Massa inhomogen besar

-Curiga rektosigmoid disentri
-Masa kompleks pelvis (s), malignancy
-Hydronefrosis, hidroureter
-Hepar,GB,lien kesan DBN

Diagnosa
Acute abdomen ec.
Sup.tumor abdomen
PLANNING EXAMINATION