lapsus ca recti
TRANSCRIPT
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MORNING REPORT
Sunday, September 7th
2014
COASS IN CHARGE:
Risa Natalia Siburian
Christian Julio
MODERATOR : dr. Sri Sunarti SpPD
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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
.
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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
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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
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LABORATORIUM RESULT
Hb 5.90 g/dl 11,4-15,1 g/dl GDS 110
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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
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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
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CXR
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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
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ECG (Sept 7th2014)
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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
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CUE AND CLUE PL Idx PDx PTx
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
CUE AND CLUE PL Idx PDx PTx
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CUE AND CLUE PL Idx PDx PTx
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 palpebral (+/+)
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
CUE AND CLUE PL Idx PDx PTx
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CUE AND CLUE PL Idx PDx PTx
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 palpebral (+/+)
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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