HEMORRHOIDS CASE REPORT 2016

CASE REPORT

Laura Nanda Prameswari

201510401011079
Preceptor : Dr. dr. Bambang Arianto, Sp.B, FINACS

A. PATIENT IDENTITY

Name : Mrs. S

Age : 76 Years Old

Address : Kedung pengkol VI/16

Job : Tailor

Last education : Junior High School

Hospitalize : 29th May 2016, 13.30 AM

Registry number : 774361

B. SUBJECTIVE

ANAMNESIS
Main complaint :

Rectal bleeding

HISTORY OF PRESENT ILLNESS :

Patiens present with rectal bleeding since approximately 3 days ago,

dripping fresh blood after defecation. The blood is bright red. The

bleeding was not associated with pain. There is no lump in the anal

area. There is itching after defecation. The patient also has a weakness

on the right side of body and difficulty talking since 3 days ago in the

morning when the patient wake up. decrease appetite (+), fatigue (+),

nausea (-), vomiting (-), febrile (-).

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 HEMORRHOIDS CASE REPORT 2016
HISTORY OF PAST ILLNESS:

History of hemorrhoid (+) since 6 years ago, the patient never get

treatment.

History of any operation is denied.

Hypertension (+), DM (-)

SOCIAL HISTORY: Patients work as a tailor, patients always sit

during work more than 8 hours a day during 25 years. Rarely eating

vegetables and fibrous food, rarely drinking water.

ALLERGIES HISTORY : Denied

C. GENERAL STATUS :

General state : Weak

Blood pressure :130/70 mmHg

HR : 86x/minute

RR : 22x/ minute

T ax : 36,5 oC

Head/Neck : A+/I-/C-/D-

Thorax

I : Normochest, symmetric, retraction (-)

P : Movement of the chestwall symmetric, crepitation (-),deviated
trachea (-), widened intercostals space (-)
P : Sonor/Sonor
A : Vesicular +/+, Ronkhi -/-, Wheezing -/-
Cor

I : Ictus does not seem

P : Ictus no palpable, thrill (-)

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 HEMORRHOIDS CASE REPORT 2016
P : heart border normal

A : S1S2 single, Gallop (-), Murmur (-)

Abdomen

I : Flat simetris _ _ _

P : Soepel , tenderness(-), _ _ _ H/L/R no palpable,

_ _ _

P : Tympani (+)

A : Bowel sounds (+) normal

Ekstremitas :

o Warm acral

+ +

+ +

o Oedema

- -

- -

o Cyanosis

- -

- -

o CRT < 2 dtk

D. NEUROGICAL STATUS

Level of consciousness : CM/ 456

Meningeal signs : Negatif

Cranial nerve : Isokor round pupil diameter 3mm/3mm, light

reflex +/+, parese N. XII dextra

Motoric function :45

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45

Sensoric function : Paresthesia dextra

Physiologis reflex : +2 +2

+2 +2

Pathological reflex : Negatif

Otonomic system : Normal

E. LOCALIST STATUS

Regio Anal

o I : Mass (+) diameter 0,5 cm, hiperemi (+), swelling (-), fix, prolapsed

(+)

o P : Can not entered manually, Pain (-)

RT: Anal sphincter normal, ampula recti not colaps, mucosa rectum: dilated

veins, anal mass (+), tenderness (-), handscoen: faeses (+), blood (+),

mucus (-)

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 HEMORRHOIDS CASE REPORT 2016
F. LABORATORY FINDINGS

Complete blood count (29/05/2016)

Hb : 6,4

Lekosit : 13.220

HCT : 20,1%

Trombosit : 424.000

Glucose : 142

BUN : 10

Creatinin serum : 1.3

SGOT : 24

SGPT : 24

TG : 87

HDL : 29

LDL : 132

Electrolit serum (29/05/2016)

K : 4,2

Na : 141

Cl : 103

Faal hemostatic (29/05/2016)

PPT : 9,7

INR : 0,87

APTT : 21,2

G. DIAGNOSIS

Internal Hemorrhoids Grade III + S. CVA Infark + Anemia (S. Def.

Fe)

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 HEMORRHOIDS CASE REPORT 2016
H. PLANNING DIAGNOSIS

- CT scan

- Protoscopy

I. PLANNING THERAPY

- Infusion RL 14 d/m

- PRC tranfusion 1 bag/day until hemoglobin 10

- Inj. Piracetam 4x15 mg

- Inj. Tranexamic acid 3x1

- Inj. Ranitidine 2x1

- Ardium 2x1 (500 mg)

- Consul surgeon Hemorrhoidectomy

J. PLANNING MONITORING

- General state

- Vital signs

- Rectal bleeding

- Patient complains

- Complete blood count

K. PLANNING EDUCATION

Prevention of constipation.
- Develop a regular bowel habit.
- Increase daily fiber intake to 20 30 grams.
- Increase non-caffeinated, non-alcoholic fluid consumption to at least
8 glasses per day.
- Avoid constipating medications.

Advise patient to go to the toilet in a routine time. Holding back against

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 HEMORRHOIDS CASE REPORT 2016
urge to defecate promotes straining.
Discourage patient from spending unnecessary time (e.g. reading) while
sitting at the toilet. Sitting at the toilet for long periods also promotes
straining.
Prescribe regular sitz bath (sitting and bathing in a tub of warm water). It
relieves irritation and improves perineal hygiene.

DAILY SOAP
Date Subjective Objective Assesment Planning
30/05/1
6 Rectal General Internal Planning diagnosis:
bleeding (-) state: Hemorrhoid -
Right side enough gr. III + S.
weakness (+) CVA Infark Planning therapy:
Nausea (-), VS: + Anemia - Infusion RL 14
vomiting (-), Blood pressure d/m
no other : 140/80mmHg - PRC tranfusion 1
complaints HR:84x/m bag/day until
pain while RR:22x/m hemoglobin 10
defecate (-) Tax:36,3C - Inj. Piracetam
urination: 4x15 mg
normal Head/Neck: - Inj. Tranexamic
A/I/C/D (-) acid 3x1
- Inj. Ranitidine
Thorax: 2x1
cor/pulmo: - Ardium 2x1 (500
normal mg)
- Consul surgeon
Abdomen:flat
, symmetric, Hemorrhoidecto
tenderness (-) my
_ _ _
Planning
_ _ _ monitoring :
- General state
_ _ _ - Vital sign.
- Rectal bleeding
, H/L/R no - Patient complains
palpable, - Complete blood
tympani, count
bowel sounds
(+) N

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 HEMORRHOIDS CASE REPORT 2016

Ext: normal
Status
Localist:
Regio Perianal
o I : Mass (+),
hiperemi (+),
swelling (-),
prolapsed (+)
o P : Can not
entered
manually

31/05/1
6 Rectal General Internal Planning diagnosis:
bleeding (-) state: Hemorrhoid -
Right side enough gr. III + S.
weakness (+) CVA Infark
Nausea (-), VS: + Anemia Planning therapy:
vomiting (-), Blood - Infusion RL 14
no other pressure : d/m
complaints 120/80mmHg - PRC tranfusion 1
pain while HR:80x/m bag/day until
defecate (-) RR:20x/m hemoglobin 10
urination: Tax:36,3C - Inj. Piracetam
normal 4x15 mg
Head/Neck: - Inj. Tranexamic
A/I/C/D (-) acid 3x1
- Inj. Ranitidine
Thorax: 2x1
cor/pulmo: - Ardium 2x1 (500
normal mg)
- Consul surgeon
Abdomen:flat
, symmetric, Hemorrhoidecto
tenderness (-) my
_ _ _
Planning
_ _ _ monitoring :
- General state
_ _ _ - Vital sign.
- Rectal bleeding
, H/L/R no - Patient complains
palpable, - Complete blood
tympani, count
bowel sounds
(+) N

Ext: normal
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 HEMORRHOIDS CASE REPORT 2016
Status
Localist:
Regio Perianal
o I : Mass (+),
hiperemi (+),
swelling (-),
prolapsed (+)
o P : Can not
entered
manually

01/06/1
6 Rectal General Internal Planning diagnosis:
bleeding (-) state: Hemorrhoid -
Right side enough gr. III + S.
weakness CVA Infark
(), nausea VS: + Anemia Planning therapy:
(-), Blood pressure - Infusion RL 14
vomiting (-) : 120/80mmHg d/m
Pain while HR:84x/m - PRC tranfusion 1
defecate (-) RR:18x/m bag/day until
urination: Tax:36,2C hemoglobin 10
normal - Inj. Piracetam
Good Head/Neck: 4x15 mg
apetite A/I/C/D (-) - Inj. Tranexamic
acid 3x1
Thorax: - Inj. Ranitidine
cor/pulmo: 2x1
normal - Ardium 2x1 (500
mg)
Abdomen:flat - Consul surgeon
, symmetric,
tenderness (-) Hemorrhoidecto
_ _ _ my

_ _ _ Planning
monitoring :
_ _ _ - General state
- Vital sign.
, H/L/R no - Rectal bleeding
palpable, - Patient complains
tympani, - Complete blood
bowel sounds count
(+) N

Ext: normal
Status
Localist:
Regio Perianal
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 HEMORRHOIDS CASE REPORT 2016
o I : Mass (+),
hiperemi (-),
swelling (-),
prolapsed (+)
o P : Can not
entered
manually

Complete blood
count:
Hb: 8,4
Lekosit: 10.210
HCT: 26,8
Trombosit:
390.000

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