CASE PRESENTATION

1. Identity

Name : Barni

Age : 69

Gender : Female

Tribe : Javanese

Occupation : Housewife

Address : Lemah Tamba

In houpital since : 14-12-2015

2. Anamnesis- Main complaint : the patient complained of a mass protruding through the

anus since many years ago.

- Additional complaint : difficulty defecating, discomfort in the anus

3. History of disease

the patient complained of a mass protruding through the anus since many years ago. Initially the mass protrudes only after bowel movement, then mass protrudes more often in the daily activities.

4. History of past disease

-

5. History of family disease

-

6. Physical Examination

General Status

Present StatusGeneral condition : GoodAwereness : Compos mentisBlood pressure : 140/80

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Pulse : 84x/ minuteBreathing : 20x/minuteTemperature : 36,7 C

HeadForm : normocephaleHair : black, no hair failEye : isokor pupil, anemic conjungtivas (-/-), leteric schleras (-/-)Ear : normal formNose : normal formMouth : normal form

NeckEnlargement of lymph nodes (-)Trackea is in the middleNo mass found

Thorax Lungs-pulmonaryInspection : the chest shape is symmetrical both left and rightPalpation : fremitus and vocale tactile both symmetrical left and right, crepitation (-)

Tenderness(-), rebound tenderness(-)Percussion : resonance sound in both lung fieldsAuscultation : vasicular and bronchial sound in the entire lung field, rhonchi (-/-)

whiizing (-/-)

AbdomenInspection : symmetricalPalpation : tenderness (-), mc burney (-), Percussion : tympanity sound in four quadrantsAuscultasi : bowel sound (+)

Extremities :

Upper and lower Muscle tone : normal

Movement : active / active

Mass : -/-

Stranght : 5/5

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Laboratory :

Description ResultGDS 118 mg/dLUreum 15,0 mg/dLCreatinin 0,63 mg/dLLeukosit 7940 /uLEritrosit 4,12 mm3

Hemoglobin 13,2 gr/dLHematocrit 38,5 %Trombosit 217.000

ribu/mm3

Diff.countBasofil 0,6 %Eusinofil 0,8 %Limfosit 19 %Monosit 3,1 %Segmen 75,1 %Stab 1,4 %

LEDLED 1 Jam 100 mm/jam

CoagulationCT 4’BT 2’

Diagnosis : rectal prolapse

Differential diagnosis : Hemorrhoids

Intussusception Proctitis

Prognosis : Quo ad vitam : ad bonam Quo ad fungsionam : ad bonam Quo ad sanationam : dubia ad bonam

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