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IDENTITY

Name : Mrs. M

Age : 34thyears old

Gender : Female

Address : Butung Vllage !es"ons#lty do$tor : dr. Faruly %&aya'

(".B

Date o) entry : (aturday' *$to#er+,th-+/

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ANAMNE(I(

Chief complaint: a#domnal "an

Anamnesa : su0ered sn$e / days #e)ore admtted to the

hos"tal. 1an started n the lo2era#domnal regon and then

on the all regon o) a#domnal. The "an 2as $onstantly' #lunt'and aggraated #y $hange o) "oston. There 2as omttng

one tmes. The omtt s n$ludng le)toers and 2ater. The

"atent )elt anore5a and the "atent 2as darrhea )or a )e2

days. In one day' the "atent6s darrhea s more than / tmes.

(he got )eer sn$e 4 days ago. The urne 2as normal.

History: there s a hstory o) $urretage a)ter she ge #rth

one 2ee7 ago #y md2)e.

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18Y(I9A E;AMINATI*N

G( : Medum ll' 9ons$ous

Vtal sgn

B1 : +

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General state

8ead : There s no a#normalty Eyes : There s 2as anems 9on&unta

Nose : There s no a#normalty

Ears : There s no a#normalty

Ne$7 : There s no a#normaltyThora5

I : (metr$al moement and noretra$ton.

P : o$al )remtus s smetr$.

P : resonant sounds on the lung.

A : es$ular sound 2as )ounded and no

addtonal sound.

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A#domen

I : Dstented' )ollo2 teh moton o) #reath

A : 1erstalt$ 2as de$reased

P : Tym"any' ler dea) 2as d>$ult )ounded'2ord o) "an.

P :There s de)ans mus$uler' tenderness allregon.

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Digital Rectal Touche

Anal s"hn$ter no strangle!e$tal mu$osa sl$7

!e$tal am"ulla not $olla"se

No tenderness' no mass

!elease: stool ?@' mu$us ?' #lood ?

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DIAGN*(ED

1E!IT*NITI( 9A(ED BY TE!I 1E!F*!ATI*N

1lan o) thera"y Flud thera"y

Analges$drugs

Ant#ot$drugs

9onsult

1lan o) $he$7 Daly #lood

(G a#domnal

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LABORATORY FINDINGS

%B9 : 3/',C +3

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GD( : ++ mg

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USG Abdominal

Tam"a7 e$ho $aran #e#asdserta se"tas

Dlatas loo"loo" usus

8e"ar' GB' en' "an$reas DBN

terus : u7uran #esar' tam"a7mult"el les h"ere$ho$ "adaarea $aum uter

Kesan:

Tandatanda "ertonts Dlatas usus

endometrts