MORNING REPORT

Sunday, September 7th 2014

COASS IN CHARGE:
Risa Natalia Siburian
Christian Julio
MODERATOR : dr. Sri Sunarti SpPD

SUMMARY OF DATA BASE

Mrs Siti Aisyah/49 yo/W.28
Chief complain : bloody stool
Patient presented with bloody stool last night at 10:00 pm.
Patient felt dizziness, like the world around her is spinning
and syncope before take a dump, the stool is yellow with solid
consistency but accompanied with black blood between the
stools. The patient then woke up in 5:00 AM, then the patient
once again felt dizziness and syncope, let out black tarry
stool. Patient then admitted to a doctor which referred her to
a primary health care , then referred to RSSA. In IGD the
patient then denied history of consuming local potion, NSAID.
Patient consumes 3 glass of Fanta last night.
.

The patient also felt weakness since syncope so she must

be

carried

by

her

relatives.

Patient

didnt

take

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

Physical examination
BP = 130/80 mmHg

PR = 92 bpm, regular

General appearance looked moderate ill,

RR = 20 tpm regular

Tax : 37.4C

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 - ---

VV
V V
VV

Abdomen

Flat, soefle, increased bowel sound ( 15) , traube space tympani, shifting
dullness (-)

Extremities

Warm, symmetry

Rectal

Circular mass with rough, irregular surface in rectum

Blood from rectal touche

LABORATORIUM RESULT
Hb

5.90 g/dl

11,4-15,1
g/dl

GDS

110

<200

Eritrosit

2.04

4,0-5,0 g/dL

Ureum

42.10

0-32 mg/dL

Leucocyte

12.92
103/uL

4,7-11,3
103/uL

Creatinin

0.51

0-33 mg/dL

Hematokrit

18.70%

38-42 %

Hapusan
darah
eritrosit

Normokro
m
normosite
r

Trombosit

256 103/uL

142-424
103/uL

Leukosit

Neutroph
ilia

RDW

12.20 %

11.5 % 14.5 %

Trombosit

Kesan
jumlah
normal

Eos/Bas/Neu 0/0/5/88/6/1
stab/Neu/Li
m/Mono

0-4/01/0/5167/25-33/25%

Retikulosit

0.0434x1
06

SGOT

11

0-32 u/L

Coombs
test

SGPT

13

0-33 u/L

Albumin

2.54

3.5-5.5 gr/dL

HBsAg

Negative

Globulin

1.61

2.5-3.5gr/dL

negative

LABORATORIUM RESULT
PH

7.37

7.35-7.45

Natrium

135

136-145
mmol/L

PCO2

28.5

35-45
mmHg

Kalium

3.77

3,5-5,0
mmol/L

pO2

195.7

80-100
mmHg

Chloride

114

98-10p6
mmol/L

HCO3

16.5

21-28
mmHg

PPT pasien 14.70

11.5-11.8 s

Base excess

-9.1

(-3) (+3)

PPT INR

1.25

0.8-1.30 s

Saturasi
O2

99.9

>95

APTT

25.90

27.4-28.6 s

URINALISIS
Lab
Cloudy
Color

Value

Lab

Few Cloudy

Clear

10 x

Yellow

Yellow

Epitel

4,5 - 8,0

Value

++

Cylinder

Lpf

pH

BJ

>=1,030

1,010 1,030

Hialin

Glucose

Negative

Negative

Granular

Negative

Protein

Negative

Negative

40 x

+1

Negative

Erythrocyte

8-13

Bilirubin

Negative

Negative

Dysmorphic

Hpf

Urobilinogen

Negative

Negative

Eumorphic

Hpf

Nitrit

Negative

Negative

Leukocyte

2-3

trace

Negative

Crystal

hpf

+3

Negative

Bacteria

93 x 103/mL

Keton

Leucocyte
Blood

3 hpf

5 hpf

CXR

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

ECG (Sept 7th 2014)

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

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 bpm
RR: 20 tpm
Tax: 37.4C
Pale palpebral (+/+)
Pale face
Fresh blood from
rectum
Circular mass with
rough, irregular
surface in rectum

PL

1.
Lower
GI
tract
mass
+
rectal
bleedin
g

Idx

PDx

1.1.
1. Co
Colorect
lo
al
no
Malignan
sc
cy
op
1.2.
y
Colitis 2. bi
ulcera
op
tive
sy

PTx

PMo

Bed rest
O2 nasal canule 24 L/m
IVFD NaCl
rehydration
1,000cc --< 0,9%
- 30 dpm
Confirm the
diagnosis and
determine the
stage

VS
Subj
ecti
ve
Urin
e
prod
ucti
on
CBC

CUE AND CLUE

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 : 2.04
HCT : 18.7 %

RDW : 12.20 %

PL

Idx

PDx

PTx

PMo

2.
Anemi
a
normo
chrom
e
Normo
cyter

2.1
Acute
blood
loss

Colon
oscop
y

Bed rest
Fluid
rescucitation
with NaCl 0.9%
1,000cc in 30min
IVFD NaCl
0.9% 30 DPM
PRC transfusion 2
pack/day until Hb
> 10 gr/dL

VS
Subj
ecti
ve
Hb
MCV
MC
H
Tran
sfus
sion
reac
tion

CUE AND CLUE

Mrs Siti /49 yo

Ax: Bloody stool

since yesterday 5
times.
PE:
GCS 456
BP:130/80 then
100/60mmHg
PR: 92 bpm
RR: 20 tpm
Tax: 37.4C
Pale palpebral (+/+)
Pale face
Lab:
Albumin :2.54 gr/ dL

PL

Idx

PDx

3.
3.1
colon
Hypoal
Hyper oscop
bumin
catab y
emia
olic
state
3.2 Low
intake

PTx

Diet high calory

high protein 2100
kkal/day

PMo

VS
Subj
ecti
ve

Thank You