1

Irwan/Male/ 42 yo/ MW 17
Chief Complaint:
• Black stool since 3 day ago

Present Illness History

• Black stool since 3 day ago, frequeny 2-3x/day, consistency liquid
• Abdominal pain increased since 2 weeks ago, pain in surgery scars
when moving
• Patient was known with adenocarcinoma recti, patient was already
on chemotherapy 3th cycle
• Fever (-) cough (-)
• There is no breathlesness, cough and fever
• Mixturition is normal.
Past illness history

• History of DM (+)
• History of Hypertension (-)
• History of Hepatitis (-)

Family illness history

• No Family had symptoms like this patient.

Physical Examination
VII

• General Appearance : Moderate

• Consciousness level: CMC

• BP : 119/78 mmHg

• HR : 85 x/minute

• RR : 21 x/minute

• T : 36º C

• SaO2 :99 %
• Eye VII
– conjunctiva anemic (+)
– Icteric sclera(-)
• Neck
– JVP 5-2 cmH20
• Lung:
– Inspection: statically & dynamically symmetric
– Palpation: fremitus right=left
– Percussion: sonor
– Auscultation: vesicular, Rh -/- Wh -/-
• Cor: VII
– Inspection: ictus is not seen.
– Palpation: ictus is palpated at 1 finger medial LMCS ICS V
– Percussion:
• Left border: 1 finger medial LMCS ICS V
• Right border: linea sternalis dextra
• Upper border: ICS II
– Auscultation: regular, murmur (-)
• Abdomen: VII
– Inspection: enlargement (-) abses on the regio right iliaca
– Palpation: hepar and spleen is not palpable
– Percussion: tympani,
– Auscultation: bowel sound (+) N
– CVA : flank pain (-/-)

• Extremities:
– Oedema pretibia -/-
– Physiologic Reflex +/+
– Pathologic Reflex -/-
Laboratory
VII
Items Value
Hb 9,5 gr/dl
Ht 28 %
WBC 13910 /mm3
Platelet 459000 /mm3
Diff. Count 0/0/73/20/7
PT/APTT 11,2/22,3
RBG 162
Ur/Cr 19/0,6
SOGT/SGPT 13/6
Na/K/Cl/Ca 138/3,3/104
Alb/glo 3,4/4
Chest X-Ray VII
ECG VII
Problems

• Melena
• Anemia
• Malignancy
Working Diagnosis

• Melena cb Non variceal bleeding

• Mild anemia normocytic normochrom cb
acute bleeding
• Adenocarcinoma recti pro chemotherapy 4th
cycle
• Abscess on the right illiaca
Differential Diagnosis

• Mild anemia normocytic normochrom cb

acute bleeding
Therapy

• Rest/ liquid diet, diabetic diet 1700 kkal

• Ivfd Nacl 0,9 % 8 hours/kolf
• Transamin 3 x 500 mg iv
• Vitamin K 3 x 10 mg iv
• Metronidazole 3 x 500 mg iv
• Paracetamol 3x1000 mg po
• Bolus prosogan 2 amp iv  drip prosogan 2 amp in 50
cc Nacl 0,9 % via syringe pump 13 cc/hours
• Sucralfat syr 3 x 10 cc po
Plan

Esofagogastroduodenoscopy
Colonoscopy
abscess culture
GDP, GD2PP, HbA1C
Chemoteraphy