MORNING REPORT

Name : Mr. U
Age : 46 years old
IDENTITY Sex : Male
Address : Matawolasi Village
Admission : January, 16th 2018
 HISTORY TAKING (ALLOANAMNESIS)
Chief Complain : anal pain
Anamnesis :
suffered since 10 months ago. The pain was continuously and felt sharp, and
was radiated to his waist. Others complains such as fart (+), difficult to defecate,
blood (+), sometimes black stool. Decreased appetite (+), abdominal pain (-),
Nausea (-), vomiting (-), fever (-). Urination within normal limit.
 There was history of same disease: patient was consume chemotherapy
drugs since 2 months ago
 History of same disease in family (-)
 PHYSICAL EXAMINATION

The patient was conscious with

moderate illness, under nourish

Blood Pressure 110/70 mmHg

STATUS
PRESENT Pulse = 96/m, regular, strong

Respiratory Rate = 20x/m,

regular

Temperature = 36,8 OC/Axillary

 GENERALIZED STATE

Ears : Within normal limit

Head : Within normal limit Neck : Within normal limit
Face : Within normal limit Chest : Within normal limit
Eyes : Within normal limit Abdomen : Within normal limit
Nose : Within normal limit Perianal : Localized State
Mouth : Within normal limit Upper Limb: Within normal limit
Lower Limb: Within normal limit
 LOCALIZED STATE

Perianal Region

• Inspection : multiple mass with different size, eritema (+)

• Palpation : solid mass, irregular shape, tenderness (+)
 DIGITAL RECTAL EXAMINATION

• Sphincter : not tight

• Mucosa : not smooth, irregular mass (+)
• Ampulla : difficult to assest
• Handscoen : feses (-), blood (+)
 Routine
Blood Test

PLAN OF Chemical
DIAGNOSTIC blood Test

Abdominal
USG
 WBC : 6.87
HB : 12,8
PLT : 234
NEUT : 57,2 %
LABORATORY
FINDING
GDS : 124
UREUM : 22
CREATININ : 0,5
SGOT : 22
SGPT : 17
 Susp.
DIAGNOSED Carcinoma
Recti distal
 MANAGEMENT

IVFD ANTIBIOTIK

ANALGETIC H2RA

Consult to
Digestive Surgeon