Identity

• Name : Tn. M
• Age : 53 years old
• Address : Laikandonga
• Admission :June, 19th 2016
• DPJP : dr. Faruly Wijaya S. Limba, Sp.B
 HISTORY TAKING
• Chief complain : abdominal pain
• Anamnesis :
Patient A patient refered from Dewi Sartika Hospital with abdominal
pain at all of abdomen region, thi was suffered since 1 weeks ago.
Firstly abdominal pain at left region and then spread at the other
side. The pain is knife like and it was intermitten. Patient
compliment about fever too since 2 days ago, dizziness (+), cough
(+), breathless and nausea. There wasn’t vomiting. Anorexia (+),
urinary is normal, defecation was like “goat feaces”, its dark. And it
suffered since 3 days before admitted to hospital. Last defecation
was 1 days before admitted to hospital too.
• History of unconcious (+), tb on treatment (+) but its just 4
mounth in 2007, history of consume analgetic drug for a
long time. transfusion of blood 1 zack, history of treatment
at home was amoxicilin and asam mefenamat. History of
treatment at dewi sartika hospital were Ceftriaxone,
metronidazole, ranitidin, and dexamethasone.
 Physical examination

The patient was conscious with moderate ill

BP = 120/70 mmHg
Pulse = 88x/m, regular, strong
RR = 28x/m, regular
Temperature = 38.1oC
 Generalized status

Head : Normal
Face : Normal Thorax
Eyes : conjungtiva anemis (+/+) I : Symmetrical left and right,
Nose : Normal there is no retraction
Mouth : Normal P : tenderness (-), No crackles,
Ears : Normal tumor mass (-)
Neck : Normal A : Vesiculer (+/+), additional
Extremitas : normal sound Rh (-/+), Wh (-/+)
P : Resonant in both hemithorax
 Generalized status
• Abdomen • Rectal toucher
I : Flat, follow the move of breath, sphinter tonus was good, prostat
A : Peristaltic was normal palpable (+), slip
P : Tenderness (+) at all region, mucous,tenderness (-), tumor mass
defans musculer (-), tumor (-), feceas release (+) dark (+)
mass (-), organomegaly (-)
P : Timpany sound and liver was
deaf
 Working diagnosis

Anemia gravis caused by chronic GI bleeding

susp.colitis
 LABORATORY FINDINGS
• Complete
• WBC : 16,12 (103/uL)
blood count • HB : 5,4 g/dL
• PLT : 248 g/dl

• USG : (18/ juni 2016) tampak lesi tubular buntu non-

compresible disertai penebalan dinding dan diameter.
Kesan : tanda-tanda appendicitis. Cystitis.
MANAGEMENT
• O2 nasal canul 3lpm
• IVFD
• Antibiotic
• Analgetic
• Antipiretic
• Anti hemoragic
• Consult a Surgeon