MORNING

REPORT
IDENTITY
Name
Mr. A

Age
28 y.o

Address
Poleang, Bombana

Admission
Desember, 9th 2019 (15.50 pm)

Doctor in charge
dr. Eka Krahmadi, Sp.B M.Kes.
 (10.50pm

HISTORY Anamnesis
Lead Anamnesis : a boil on the buttocks felt since 1
TAKING month ago. the patient does not feel pain. sometimes
when rubbed boils burst and eject pus. Urinate and
defecate in normal range.
• There was no history of the same symptom
Chief Complaint: • There was no history of hypertension.
Boil on the butt • There was no family history of the same disease
• There was history of treatment : Antibiotic
 (10.50pm

PHYSICAL EXAMINATION

General condition

Compos Mentis Moderate Good

illness nourished

110/80mmHg 78 x/minutes 22 x/minutes 36.5°C

BP HR RR T
 GENERAL STATE
Head : Normal
Face : Normal
Eyes : Normal
Nose : Normal
Mouth : Nomal
Ears : Normal
Neck : Normal
Chest : Normal
Abd : Normal
Superior Extremity : Normal
Inferior Extremity : Localized
Genitalia : Normal
 Localized State

Swelling (-) pus (-)

boil(+) bleeding (-) Pain (-) solid mass (+)

Inspection Palpation

Perianal
Region
CLINICAL FINDING
 PLANNING

Routine Blood Test

Blood Chemistry Test

 10/12/2019

PARAMETER RESULT REFERENCE VALUE

WBC 10.82 10*3/Ul 4.0-10.0

RBC 5.60 10*6 /Ul 3.50-5.50
HB 14,7 g/dL 12.0-16.0
PLT 176 fL 100-300
10/12/2019

PARAMETER RESULT REFERENCE VALUE

BLOOD SUGAR 98 mg/dl 70 – 180

DIAGNOSE

Fistel Perianal
 Non-
pharmalogical Pharmalogical
MANAGEMENT
Education •IVFD
Rest •Antibiotic
•Analgesic
•PPI
Consult General Surgery .
Thankyou