Case report

Identity
Name
: Mrs. A
Sex
: Female
Age
: 48 years
Address : Kandis siak
Occupation : Housewife
Admitted to hospital : 5th April 2016
MR No. : 871247

Main Complaint
Ruptured lump on the perianal area
since 2 days before admitted to
hospital

Present symptoms
(auto anamnesis)
2 days before admitted to hospital,
the lump on the perianal area had
ruptured by itself. The patient feels
pain and the left butt feels thickened.
Also there are yellowish liquid and
blood discharge, fever (+). There are
no complaints in defecation and
urination, diarrhea (-), no history of
infection in genitourinary area.

Present symptoms
(auto anamnesis)
1 week before admitted to hospital,
the patient told that there is a lump
on the perianal area. The lump
became bigger from the size of
marbles to the size of chicken egg,
the lump looked reddish and felt
tender, fever (+), pain (+) increased
when sitting.

 Past illness
The patient never has complaints and
symptoms like this.

Family history
There are no family history with these
symptoms
DM (-)

 Social history
The patient is a housewife.

Physical examination
General state
moderate
Conscious state
Vital signs

: seem to be a
pain
: compos mentis

Blood pressure : 130/80 mmHg

Heart rate : 78 beats/min
Respiration rate : 20 breaths/min
Temperature : 37,3 OC

 Head and neck

Thorax
Normal
Abdomen
Extremity
Lymph nodes
Genitourinary

: Normal
:
: Normal
: Normal
: Normal
: Localist status

Localist status
Genital : Signs of infection (-)
Inspection :

Erythema (+), ping-pong balls sized,

pus (+), blood (+).

Palpation :

Tenderness (+), undulated, warm(+), a

lump with diameter 6 cm.

 picture

 Rectal toucher
Anal sphincter muscle tone is normal,
palpable lump at 7 oclock direction,
pain (+), feces (-), blood (-), mucus (-).

Working diagnosis
Perianal Abscess

Workup examination

Hb : 11,5 g/dl
HT : 28, 4 %
Leukocyte : 43.900
Platelet : 878000
Blood chemistry
Glucose: 83 SGOT : 14, 8
Ureum : 40 SGPT : 14
Creatinine : 1,3

Definitive Diagnosis
Perianal Abscess

Treatment
Non-pharmacologic therapy
Bed rest
IVFD 20 drops/min

Pharmacologic therapy
Inj. Metronidazol 3 x 1 fls
Inj. Cefriaxone 1 x 1 gr iv
Ketorolac 1 x 1 amp

Perianal abscess
Definition
Perianal abscess is an infection of the
soft tissue around the anal canal, with
the formation of the abscess cavity.

Etiology
Generally caused by bacteria such as
staphylococci and Escherichia coli (the
most common cause).

Clinical manifestations
Pain, which is usually constant,
throbbing, and worsen when sitting.
Irritation of the skin around the anus,
including swelling, redness, and pain.
Discharge of pus.
Constipation or pain associated with
defecation.