DUTY REPORT3rd February 2016 Ca Cervix stadium IVresidif with fistula rectovagina and bone metastatic withgeriatry infection perspective

Resident on duty : dr. Shiddiq & dr. AgilCoass on duty : Giavanny & NimaSupervisor : dr Soroy Lardo SpPD FINASIMDivisi /Sub SMF Penyakit Tropik dan InfeksiIndonesia Army Central Hospital Gatot Soebroto

PATIENT’S IDENTITY•Name : AU•Sex : Female•Place, Date of Birth : 10th April 1943•Age : 73 years old•Occupation : Housewife•Religion : Moslem•Marital Status : Married•Address : Jl. H. Awaludin II•Date of admission : 3rdFebruary 2016

Chief complaint : smelly discharge from vaginal and rectal for approximately 1 month

Additional complaint : nausea and weakness

3

History of Present IllnessHistory of Present Illness :Patient came to the ward with chief complaint of smelly discharge from vagina and rectal for ± 1 month.

1 year before admission, she complained smelly vaginal and rectal discharge, then she came to primary health care and felt better. But 2 weeks later she reported the same complaint.

4 months before admission, she came to RSAL Mintoharjo with the same complaint as before and the doctor told her there was a hole between her vagina and rectal. Then she reffered to RSPAD Gatot Subroto

Before the complaint of smelly discharge from vagina and rectal, she also had a vaginal bleeding.

Because of the smelly discharge she had a decrease appetite

she also reported nausea and vomit, abdominal discomfort (+), weakness (+), she can not walk and just lied on the bed. Weight loss (+) ± 10 kg within 4 months.

Patient did not have a history of fever, no sore throat, no cough, and no symptoms of flu, no history of heavy breathing, no history of chest pain. No complaint of urinate and defecate

*The patient treated by internal medicine department, obsgyn and surgery department

History of Past IllnessShe diagnosed with Ca Cervix since she was 48 years old and had radiotherapy and chemotherapy

DM (-)HT (-)Kidney disease (-)Lung disease (-)

History of family illness•No history of Ca Cervix•No family members have the similar symptoms

History of Socio-Habits•She neither smokes, drinks alcohol, nor uses

any forbidden drug

Physical Examination•General State : Mildly sick•Consciousness : Fully alert

Vital Signs•Blood Pressure : 90/70 mmHg•Heart rate : 86 bpm (regular)•Respiratory Rate : 20 times/minute•Temperature : 37,1 oC

•Body Weight : 45 kg•Body Height : 156 cm•BMI : 18.49 (Normoweight)

General Examination•Head : Normocephal

Eye : anemic conjunctiva (-/-), icteric sclera (-/-)

Ears : discharge (-)

Nose : septum deviation (-), discharge (-)

Mouth : coated tongue (-), hyperemic pharynx (-), normal T1-T1, pale mouth mucosa (-), dried mucosa (-)

•Neck : lymph nodes enlargement (-)

•Thorax: symmetric, intercostals retraction (-)

COR Inspection: Ictus cordis (-) Palpation: heave (-), lift (-), thrill (-) Percussion:

Right border: ICS V, linea midclavicularis dextra Left border : ICS V, linea midclavicularis sinistra Heart waist: ICS IV, linea parasternal sinistra

Auscultation : regular 1st and 2nd heart sound, murmur (-), gallop (-)

▫PULMO• Inspection : chest within normal shape, symmetries on static

and dynamic state• Palpation : tactile vocal fremitus both lungs were symmetries,

chest expansion symmetries• Percussion : resonant both lungs• Auscultation : vesicular breathing sounds, rales (-/-), wheezing

(-/-)

•Abdomen : flat, not distended

timpani, no enlargement of liver & spleen, pain tenderness (-)

• Urogenital : no examination (patient refused).

•Extremities : CRT < 2 seconds, lower limb athropy (+)

Laboratory ResultsRESULT Nilai Rujukan

27/01/2016

Hemoglobin 12.7 12-16 g/dL

Hematokrit 39 37-47 %Eritrosit 4.3 4,3-6,0 juta/μLLeukosit 18670 4.800-

10.800/μLTrombosit 211000 150.000-

400.000/μLMCV 90 80-96 fLMCH 27 27-32 pgMCHC 33 32-36 g/dL

Jenis Pemeriksa

an

Hasil Nilai Rujukan26/01/2016

PT Control = 11.0Patient = 10.5 9.3 – 11.8 sec

APTT Control = 33.1Patient = 31.0 31 – 47 sec

SGOT 36 < 35 U/LSGPT 14 < 40 U/LAlbumin 2.4 3.5 – 5.0 g/dLUreum 67 20 – 50 mg/dLCreatinin 1.5 0.5 – 1.5

mg/dLGDP 92 70 – 100

mg/dLGD2PP 124 < 140 mg/dLNatrium 131 135 – 147

mmol/LKalium 4.7 3.5 – 5.0

mmol/LClorida 97 95 – 105

mmol/L

•Radiology Result (18th January 2016)▫Conclusion : Fistel Rectovagina

RESUMEMrs. AU, 73 years old, came to ward with the chief complaint of smelly discharge from vaginal and rectal for ± 1 year and heavier for 1 month before admission. Because of the smell she loss her appetite, nausea and vomit (+), and weight loss ± 10 kg within 4 months.

There was a history of Ca Cervix and she had radiotherapy and chemotherapy

Physical examination: atrophy lower limbLaboratory results showed Leukocytosis (18670), elevated

SGOT (36), hipoalbuminemia (2.4), hiponatremia : 131, ureum (67)

Diagnosis•Working diagnosis

• Ca Cervix IV residif with fistula rectovagina and bone metastatic

• Poor intake on geriatry

List of Problem

• Ca Cervix IVresidif with fistula rectovagina and bone metastatic

• Poor intake on geriatry

Discussion• Ca Cervix IV residif with fistula rectovagina and bone metastatic

▫From anamnesis ▫A history of Ca cervix and had rectovaginal smelly discharge▫Weight loss 10 kg within 4 months

▫Lab result: Leucocytosis ▫From Radiography

●Fistula rectovagina sign of bone metastatic

Planning therapy:IVFD NaCl 0.9% 500 cc/6 hoursCefotaxim 3x1 gram IVVitamin C 2x1 ampParacetamol 3x500 mg prnSurgery from surgery department

• Poor Intake on Geriatry• Anamnesis:

▫Loss of appetite▫Nausea, vomiting, weakness, weight loss 10 kg

within 4 months

• PE▫BMI 18.49 if there is no treatment she will fall to

underweight

• Planning therapy▫Diet 1700 kkal▫Ranitidin 2x50 mg IV▫Ondancentron 3x4 mg IV▫Education: eating small but frequent▫NGT if the patient refuse to take her meal

Prognosis•Quo ad Vitam : dubia •Quo ad Functionam : ad malam•Quo ad Sanationam : ad malam

Infection Perspective

Ca cervix 75 y.o

Cancer

Chronic inflamma-tion

Decrease condi-tion

Innate Humoral immu-nity

Infection Colonization Abnormality coagulation

Sepsis

Poor intake

Additional discussion•In this patient with ca cervix have a

decrease condition, because of chronic inflammation from the cancer.

•Complaint of poor intake association with smelly discharge from her rectovaginal makes her condition more decrease she complained general weakness and unable to walk.

•This condition makes her more easy to having infection which leads her to sepsis.

•Sepsis itself is very dangerous, especially she is a geriatric patient. So we need to look more carefully for her proper treatment

•1st step, we can correct her diet. If she can not take her meal properly, we should use NGT to maintain her diet.

•We hope with proper diet, her complaint such as vomit, nausea, abdominal discomfort and also general weakness can be resolved

THANK YOU