MORNING

REPORT
15 September, 2023
IDENTITY

● Name : Suyoto
● Age : 63 yo
● Gender : Male
● Address : Batu
● Arrival date : 15 September 2023
● Patient type : non Trauma
 ANAMNESIS

Main complaint: Pain and anal lump

Current Medical History: The patient pain at his anal lump since last
night. History of anal lump 1 year ago, last defecation 1 day ago, soft
consistency, flatus +

Medical History: HT +, DM -

Drug: Amlodipine 1x5mg

Allergies: eggs and broiler chicken

 GENERALIST STATUS
Awareness : Composmentis
KU: cukup
GCS: 456
SpO2: 96% RA
BP: 144/78 mmHg
HR : 78x/mnt
RR 20x/mnt
Tax 36.4 C
 Physical Examination
Head: THORAX :
Konjungitva anemis (-/-), sklera icterik Cor:
(-), PBI 3mm|3mm (isochor), direct light Inspection: ictus cordis not seen
reflex +/+, indirect light reflex +/+, Palpation: ictus cordis palpable in ICS 5
ptosis (-/-) MCL S
Auscultation: S1 S2 single, takikardia,
Neck : murmur (-), gallop (-)
Inspektion: trachea deviation(-) Pulmo:
Palpation: lymph node enlargement(-) Inspection: chest shape normal,
Auscultation : Bruits (-) retraction (-)
Palpation: chest D/S simetric wall chest
movement
Perkusi: sonor
Auscultation:
Ves/ves, rh (-), wh (-)
 Physical Examination

Rectal Touche:
Abdomen
Inspection: visible reddish protruding anus,
Inspection:
fissure -, abscess -
Flat, inflammation (-) scar (-) eritema (-) defans
Palpation: strong sphincter tone, smooth anal
muscular (-)
mucosa, tenderness in all directions, convex
Auscultation : BU (+)
median sulcus,
Percution: timpani
Bulbocavernous Reflex +, Cremaster Reflex +
Palpation:
Handscoen : blood -, feses -
Soefl (+) Pain (+) superficial and deep.
---
Extremity:
---
Red Dry Warm Acral, CRT< 2, pitting oedem (-)
---
Laboratorium
15 September
2023
Clinical Pictures
 PROBLEM LIST & PLANNING
Problem list Definitive Diagnosis Planning Planning Therapy
Diagnosis

Mr. S, 63 YO, Pain on lump from his anal lump • Hemorhoid grade IV • - • IVFD RL 20tpm
since1 year ago, last defecation 1 day ago, soft • Inj ketorolac 30mg
consistency, flatus + • Inj ranitidin 50mg

Awareness : Composmentis • rendam air garam

KU: cukup pagi dan sore
GCS: 456 SpO2: 96% RA BP: 144/78 mmHg selama 2 menit, 1
HR : 78x/mnt RR 20x/mnt Tax 36.4 C sendok garam
dapur dlm air 1
baskom uk selebar
RT bokong
Inspection: visible reddish protruding anus
Palpation: strong sphincter tone, smooth anal
mucosa, tenderness in all directions, convex
median sulcus,
Bulbocavernous Reflex +, Cremaster Reflex +
Handscoen : blood -, feses -
Tn.Suyoto/63th/1C/Hemoroid grade IV + susp. Rectal touche :
BPH/dr.Freddy, Sp.B.KBD, dr.Septi, Sp.U Inspeksi : tampak benjolan dari anus
berwarna abu-abu, fissura -, abcess -
S: Nyeri di anus Palpasi : padat, nyeri tekan +

O: P
TTV IVFD NS 20 tpm
KU: cukup GCS: 456 SpO2: 95% RA TD: 142/97 Inj ketorolac 3x30mg
mmHg HR : 80x/mnt RR 20x/mnt Tax 35.9 C Inj ranitidin 50mg
PO herroid 4x1 tab
Pemeriksaan fisik PO ibuprofen 3x400 mg
K/L : a/i/c/d -/-/-/- Drip KCL 50 mg dalam NS 500cc
Thorax: simetris
Pulmo : ves +/+ rh -|- wh -l-Cor : S1S2 tunggal,
murmur - gallop –
Abd: Soefl, BU +,nyeri tekan - - -
--- -+-

Ext : AKHM, crt<2 s, edema --/--

Tn.Suyoto/63th/1C/Hemoroid grade IV + susp. Rectal touche :
BPH/dr.Freddy, Sp.B.KBD, dr.Septi, Sp.U Inspeksi : tampak benjolan dari anus
berwarna abu-abu, fissura -, abcess -
S: Nyeri di anus Palpasi : padat, nyeri tekan +

O: P
TTV IVFD NS 20 tpm
KU: cukup GCS: 456 SpO2: 97% RA. TD: 156/99 Inj ketorolac 3x30mg
mmHgHR : 90x/mnt RR 16x/mnt Tax 34 C Inj ranitidin 50mg
PO herroid 4x1 tab
Pemeriksaan fisik PO ibuprofen 3x400 mg
K/L : a/i/c/d -/-/-/- Drip KCL 50 mg dalam NS 500cc
Thorax: simetris
Pulmo : ves +/+ rh -|- wh -l-Cor : S1S2 tunggal,
murmur - gallop –
Abd: Soefl, BU +,nyeri tekan - - -
--- -+-

Ext : AKHM, crt<2 s, edema --/--

THANK YOU