AFTERNOON REPORT

Friday, May 28th 2021

Case from Tuesday, May 25th 2021
PATIENT IDENTITY

• Name : PDA
• Medical record : 21019920
• Age : 19 years old
• Sex : Male
• Religion : Hindu
• Marital status : Single
• Address : Jln. Pulau Saelus, Gang V, No. 9, Denpasar
• Admitted date : May 18th 2021
ANAMNESIS
Chief complaint : Weakness
Present medical history:
The patient came to Sanglah General Hospital and was referred from Surya Husada Hospital with the
main complaint of weakness. Complaints of weakness have been felt since approximately 2 weeks before
being admitted to the hospital. Limp feeling throughout the body. Complaints of weakness are felt
especially during activities, such as walking long distances, and improve with rest. Complaints of
weakness accompanied by dizziness. Before the patient complained of weakness, the patient had bloody
bowel movements.
The patient complained of bloody bowel movements since approximately 1 month before being
admitted to the hospital. Blood is said to be a fresh, dripping red color. Defecating blood occurs when the
patient strains too hard or forces to defecate. A blood stool appears accompanied by a lump in the rectum
which is said to be unable to pass on its own and is said to be a little painful. The bumps are said to be
brown like the color of the skin. The patient is also said to have experienced a loss of 1 kilogram of body
weight which was realized 1 day before being admitted to the hospital.
When examined (May 25, 2021), the patient said that he still felt weak, the lump in the anus was said
to be still there, pain in the anus was absent, nausea and vomiting were absent, fever, cough, and
shortness of breath were absent to. Good appetite and drink. When defecating is said to have no
complaints and urinating is normal.
ANAMNESIS
 Past medical history:
Previously, the patient claimed to have experienced complaints of bloody bowel
movements accompanied by mucus, approximately 5 years ago. At that time, the patient
received treatment and recovered, but the patient admitted that he forgot what
medicine he took.
History of heart disease, hypertension, kidney is denied. History of drug or food
allergies is denied. Operation history is said to be absent.
 Medication history :
While at Surya Husada Hospital, the patient received treatment in the form of
antibiotics (taken 2 times a day), gastric medication (taken 3 times a day), drugs that
were inserted into the rectum (once), and blood booster drugs (taken 2 times a day) .
The patient admitted that he forgot what medicine he was taking.
At Sanglah General Hospital, the patient received 4 bags of blood transfusion (PRC).
The patient said that he had a fever after the transfusion, but got better with the
administration of fever-reducing drugs. Other complaints such as redness, itching, and
shortness of breath were denied.
ANAMNESIS
 Family history :
There was no family member with the same complaints. History of diabetes mellitus,
hypertension, asthma, hepatitis, heart disease were denied.

 Personal and Social history :

The patient is an undergraduate student at IPBI (2nd semester). The patient has
history of smoking (electric) and drinking alcohol. Patients consume approximately 100
mL of liquid vape per month. The patient is said to have last consumed alcohol during
junior high school, and sometimes when there are events with his friends.
Patients said he consume meat quite often, but the consumption of fruits and
vegetables is very insufficient. The patient really likes to eat instant noodles. Tea
consumption is rare, only occasionally when he feel unwell. Coffee consumption is
denied.
PHYSICAL EXAMINATION
Present Status

• General appearance : severe ill

• Consciousness : Compos mentis
• GCS : E4V5M6
• Blood pressure : 110/60 mmHg
• Pulse rate : 64x/min, regular, adequate content
• Respiration rate: 20x/min, regular
• Temperature axilla : 36.5 0C
• NRS : 0/10
• Sp02 : 98% on room air
• Height : 176 cm
• Weight : 74 kg
• BMI : 23,9 kg/m2
PHYSICAL EXAMINATION
General Status

• Head : Normocephali
• Eye : Pale Conjunctiva (+/+), icteric sclera (-/-), pupil’s reflex (+/+) isochor
• ENT
Ear : Discharge (-/-)
Nose : Discharge (-/-)
Throat : T1/T1, pharyngeal hyperemic (-)
• Neck : JVP 5 ± 3 cm H2O, lymphnode enlargement (-)
• Mouth : cyanosis (-), oral ulcus (-)
PHYSICAL EXAMINATION
General Status
CHEST : Symmetric on static and dynamic, no deformity
Cor :
Inspection : Ictus cordis unseen
Palpation : Ictus cordis palpable at MCL sinistra, ICS V, thrill (-)
Percussion : Right border : PSL dextra ICS IV
Left border : MCL sinistra ICS V
Auscultation : S1 S2 single reguler, murmur (-)
Pulmo:
Inspection : Symmetric on static and dynamic
Palpation : Vocal fremitus was normal on the entire lung
Percussion : sonor | sonor
sonor | sonor
sonor | sonor
Auscultation : vesicular + | + rhonchi -|- wheezing -|-
+|+ -|- -|-
+|+ -|- -|-
PHYSICAL EXAMINATION
General Status
Abdomen :
Inspection : Distention (-), Meteorismus (-),
Auscultation : normal bowel sound (+)
Percussion : Tympanic (+), Ascites (-), shifting dullness (-), undulation (-)
Palpation : Abdominal pain (-), ballottement (-), CVA pain (-)
Liver : Unpalpable
Spleen : Unpalpable
Extremity : Warm +|+ edema - |- CRT <2 s
+|+ -|-
LABORATORY EXAMINATION:
Complete Blood Count (May 18th,2021)
LABORATORY EXAMINATION:
Peripheral Blood Smear (May 18th,2021)
LABORATORY EXAMINATION:
May 18th,2021
LABORATORY EXAMINATION:
May 19th,2021
LABORATORY EXAMINATION:
May 20th,2021
LABORATORY EXAMINATION:
May 22nd,2021
LABORATORY EXAMINATION:
May 23rd,2021
RADIOLOGICAL EXAMINATION :
(May 18th, 2021)

Clinical: severe anemia

AP Thorax Photo (Asymmetric):

Soft tissue: no visible abnormalities

Bones: no visible abnormality
Normal left and right diaphragm
The right and left pleural sinuses are sharp

Cor: large and normal in shape. CTR 56%

Pulmo: no visible consolidation / nodule.
Normal bronchovascular streak

Impression:
Cor and Pulmo did not appear abnormal
ASSESSMENT
1. Severe hypochromic microciter ec IDA
2. Grade III internal hemorrhoids
MANAGEMENT
 IVFD NaCl 0,9% 2580 cc every 24 hours (20 tpm)
 Anti hemoroid suposituria every 24 hours
 SF 200 mg every 8 hours I.O
 Vitamin C 100 mg every 8 hours I.O
 PRC transfusion 1-2 bags/day up to Hb ≥10 gr/dL
MONITORING

MONITORING

• General Condition
• Vital Sign and laboratory result
• Nutrition
PROGNOSIS

• Ad vitam : dubia ad bonam

• Ad functionam : dubia ad bonam
• Ad sanationam : dubia ad bonam
Thank You