lapsus CA Recti

8/10/2019 lapsus CA Recti

1/18

MORNING REPORT

Sunday, September 7th

2014

COASS IN CHARGE:

Risa Natalia Siburian

Christian Julio

MODERATOR : dr. Sri Sunarti SpPD


2/18

SUMMARY OF DATA BASEMrs Siti Aisyah/49 yo/W.28

Chief complain : bloody stool

Patient presented with bloody stool last night at 10:00 pm. Patientdizziness, like the world around her is spinning and syncope before ta

dump, the stool is yellow with solid consistency but accompanied with b

blood between the stools. The patient then woke up in 5:00 AM, then

patient once again felt dizziness and syncope, let out black tarry st

Patient then admitted to a doctor which referred her to a primary he

care , then referred to RSSA. In IGD the patient then denied histor

consuming local potion, NSAID. Patient consumes 3 glass of Fanta last nig

.


3/18

The patient also felt weakness since syncope so she must be carried

her relatives. Patient didnttake any medication to relieve her complaint

Past Medical History & Medication: unremarkeble

Social history: she is married, has 3 children, she is a house wife.

Family history: No history of diabetes her family


4/18

Physical examinationBP = 130/80 mmHg PR = 92 bpm, regular RR = 20 tpm regular Tax : 37.4C

General appearance looked moderate ill, GCS 456 ,

Head Pale palpebra (+/+)

Neck JVP R + 0 cmH2O 30 degree, lymphnode enlargement -

Chest Heart: Ictus invisible and palpable at ICS V at MCL Sinistra

LHM ~ ictus, heart waist ( -)

RHM ~ SL D

S1, S2 single, murmur -

Lung: Symetric, Rh - - Wh - - V V

- - - - V V

- - - - V V

Abdomen Flat, soefle, increased bowel sound ( 15) , traube space tympan

dullness (-)

Extremities Warm, symmetry

Rectal Circular mass with rough, irregular surface in rectumBlood from rectal touche


5/18

LABORATORIUM RESULT

Hb 5.90 g/dl 11,4-15,1 g/dl GDS 110


6/18


7/18

LABORATORIUM RESULT

PH 7.37 7.35-7.45 Natrium 135 136-145 m

PCO2 28.5 35-45 mmHg Kalium 3.77 3,5-5,0 mm

pO2 195.7 80-100 mmHg Chloride 114 98-10p6 m

HCO3 16.5 21-28 mmHg PPT pasien 14.70 11.5-11.8

Base excess -9.1 (-3)(+3) PPT INR 1.25 0.8-1.30

Saturasi O2 99.9 >95 APTT 25.90 27.4-28.6


8/18

URINALISIS

Lab Value Lab Value

Cloudy Few Cloudy Clear 10 x

Color Yellow Yellow Epitel ++ 3

pH 6 4,5 - 8,0 Cylinder - Lpf

BJ >=1,030 1,0101,030 Hialin - 2

Glucose Negative Negative Granular - Negative

Protein Negative Negative 40 x

Keton +1 Negative Erythrocyte 8-13 3 hpf

Bilirubin Negative Negative Dysmorphic - Hpf

Urobilinogen Negative Negative Eumorphic - Hpf

Nitrit Negative Negative Leukocyte 2-3 5 hpf

Leucocyte trace Negative Crystal - hpf

Blood +3 Negative Bacteria + 93 x 10


9/18

CXR


10/18

CXR

PA position, asymmetric, KV enough, less inspiration

Soft tissue normal, bone normal

Trachea in the middle

Right and left hemidiaphragm were dome shape

Costo phrenico angel d/s were sharp

Right and left lung: normal bronchovesicular pattern

Cor: site normal, size 50% apex embedded, cardiac waist (+)

Conclusion : normal


11/18

ECG (Sept 7th2014)


12/18

ECG

Sinus tachycardia, Heart rate 100 bpm

Frontal Axis : normal

Horizontal Axis : counter clockwise rotation

PR interval : 0.16

QRS complex : 0.08

QT interval : 0.36

Conclusion : Sinus tachycardia, Heart rate 100 bpm

CUE AND CLUE PL Idx PDx PTx


13/18


Mrs Siti /49 yo

Ax:

Yellow stool with solid

consistency but

accompanied with

black blood between

the stools.

Bloody streak

PE:

GCS 456

BP:130/80 mmHg

PR: 92 bpmRR: 20 tpm

Tax: 37.4C

Pale palpebral (+/+)

Pale face

Fresh blood from

rectumCircular mass with rough,

irregular surface in

rectum

1.

Lower

GI tract

mass +

rectal

bleeding

1.1.

Colorectal

Malignanc

y

1.2.

Colitisulcerati

ve

1. Co

lon

os

co

py

2. biops

y

Bed rest

O2 nasal canule 2-4

L/mIVFD NaCl rehydration

1,000cc --< 0,9% - 30

dpmConfirm the diagnosis

and determine the

stage



14/18


Mrs Siti /49 yo

Ax:

General weakness

Rectal bleeding since

10 pm September 6th

2014

PE:GCS 456

BP:130/80 then

100/60mmHg

PR: 92 bpm

RR: 20 tpm

Tax: 37.4C


Pale face

Lab:Hb : 5.90 gr/dL

RBC : 2.04HCT : 18.7 %

RDW : 12.20 %

2.

Anemia

normoc

hrome

Normoc

yter

2.1 Acute

blood

loss

Colono

scopy

Bed restFluid rescucitation with

NaCl 0.9% 1,000cc in

30min IVFD NaCl

0.9% 30 DPM

PRC transfusion 2pack/day until Hb > 10

gr/dL



15/18


Mrs Siti /49 yo

Ax: Bloody stool since

yesterday 5 times.

PE:

GCS 456

BP:130/80 then100/60mmHg

PR: 92 bpm

RR: 20 tpm

Tax: 37.4C


Pale face

Lab:

Albumin :2.54 gr/ dL

3.

Hypoalb

uminem

ia

3.1

Hyperc

ataboli

c state

3.2 Low

intake

colono

scopy

Diet high calory high

protein 2100 kkal/day


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