PRESKAS BEDAH

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CASE PRESENTATION A. PATIENT IDENTITY Name : Mr. S Age : 73 years old Sex : Male Address : Cupang Religion : Moslem Marital Status : Married B. ANAMNESIS Main Grievance Having lump on the rectal Historical of Present Disease The patient came to the hospital of Arjawinangun because there was a lump on his rectal since 2 months ago. The patient complained of increasingly enlarged lump on his rectal. The patient complained that he got bowel problems, that’s disturb his activity because he was founded a movement disorder and continuously pain around of his genital area.

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BEDAH

Transcript of PRESKAS BEDAH

CASE PRESENTATIONA. PATIENT IDENTITYName: Mr. SAge: 73 years oldSex: MaleAddress: CupangReligion: MoslemMarital Status: MarriedB. ANAMNESIS Main GrievanceHaving lump on the rectal Historical of Present DiseaseThe patient came to the hospital of Arjawinangun because there was a lump on his rectal since 2 months ago. The patient complained of increasingly enlarged lump on his rectal. The patient complained that he got bowel problems, thats disturb his activity because he was founded a movement disorder and continuously pain around of his genital area. In addition to these symptoms, patient has no other complaints. Historical of Past Disease Hipertension (-) Diabetes Melitus (-) Historical of Family Disease Hipertension (-) Diabetes Melitus (-) The patient said there was no other family member that have same disease like him

C. MEDICAL EXAMINATIONPresent StatusGeneral Condition: ModerateAwareness: ComposmantisBlood Pressure: 120/80Pulse: 72x/minuteBreathing: 20x/minuteTemperature: 35,9 C

General StatusHead Form: Normal, Simetrical Hair: Black colour, No hair fall Eye Anemic Conjungtival, -/- Icteric Sclera, -/- Light Reflect, (+) Isocor Pupil, right = left Ear: Normal form, cerumen (-), tympani membrane intac Nose: Normal form, no deviation on septum, epitaction, -/- Mouth: Normal

Neck Enlargement of lymph nodes (-) Trachea in the middle No massThorax Lungs pulmonary Inspection: The right and left of his chest shape is symmetrical Palpation: His right and left fremitus tactile and vocal is symmetrical, crepitus (-), tenderness (-), rebound tenderness (-) Percussion: The sound of percussion are resonant in both of his lung fields Auscultation: The sound of his lung is vecular and bronchial in the entire of lung field, ronkhi -/-, wheezing -/- Heart Inspection: Ictus cordis is not visible Palpation: Ictus cortis palpable on the left of midclavicula on ICS line 5 Percussion: Upper limit ICS 3 linea parasternalis sinistra. Right limit ICS 4 linea sternalis dextra. Left limit ICS 5 linea midclavicula sinistra Auscultation: Heart sound I II pure regular, mumur (-), gallops (-)

Abdomen Inspection: Flat abdomen shape, supple, not visible skin disorders Palpation: Tenderness (-), rebound tenderness (-) Percussion: There was a whole field tympanic abdomen Auscultation: Bowel (+) Normal

EkstremitySuperior: Warm akral, edema -/-, CTR