Patient identity

Name : Mrs. T
Age : 52 years
Female gender
Occupation: Housewife
Hospital admission date: January 19, 2022
ANAMNESIS
Main problem
Painful lump on back side

History of Present Disease (RPS)

Painful lumps are felt around the anus
Complaints have been felt since more than 1 year ago
The lump is felt to be getting bigger slowly, at first it was not felt
Pain is felt intermittently, the pain increases when the patient sits and decreases when the
patient lies on his stomach
Patients often have difficulty defecating, sometimes bloody stools.
Nausea (-), vomiting (-), weakness (-)
Medical history (RPD)

History of ulcers on the back side (+)

The patient fell in the bathroom 4 years ago. Since the fall, the patient has complained of
feeling heavy in both legs and often tingling but is still able to move.
Similar complaints (-)
Operation history (-)
History of hospitalization (-)
Diabetes mellitus (-)
Kidney illness (-)
Asthma (-)
TB disease (-)
Family medical history (RPK)

Similar complaints (-)

Cardiac history (-)
Diabetes mellitus (-)
Kidney illness (-)
Asthma (-)
TB disease (-)
Social economy history

Housewives, using BPJS insurance.

Smoking (-), drinking alcohol (-).
Physical examination

General condition: Looks moderately illness

Awareness: Compos mentis
Blood pressure: 110/70 mmHg
Pulse: 89x/minute, lifting strength, regular
Temperature : 36.3 oC
Breathing : 20x/minute
SP02 : 98%
VAS score is 4 the patient expression heart little more
From generalis examination : head to toe is normal
Anus : visible skin tag bumps around the anus, there is a hole in the perianal region around 5
o'clock
Additional examination : the APTT test is 19.1 is low
The radiology examination, the pulmo and cor is normal
Input the additional examination : fistulografi & endoanal ultrasound
The differensial diagnosis is fistula perianal, anusitis, abses anorectal, hemoroid interna
Main diagnosis is fistula perianal
Treatment in the patiens is pre op  infus RL 20 tpm, claneksi inj 3x1 vial  post op 
infus RL 20 tpm, claneksi inj 3x1 vial, tramadol inj 3x50 mg iv, ibuprofen inj 4x1 amp iv,
ondan 3x8 mg iv, Per-oral lactulose syrup 2x15 ml
Education  Explain to the patient about the patient's disease, namely perianal fistula,
Explain to the patient to be admitted to the surgical ward, Educate patients about the
possibility of surgery, Educate for post-operative phased mobilization, Educate patients to
soak with warm water in a basin post-operatively and after defecation, Educate patients to eat
high-fiber vegetables & fruits
Prognosis  ad vitam, ad sanationam, ad fungtionam is dubia ad bonam
This is the picture before operation, and when the patiens operation