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

Normokrom
normositer

Trombosit

256 103/uL

142-424
103/uL

Leukosit

Neutrophili
a

RDW

12.20 %

11.5 % - 14.5
%

Trombosit

Kesan
jumlah
normal

Eos/Bas/Neu
stab/Neu/Lim/
Mono

0/0/5/88/6/1

0-4/0-1/0/5167/25-33/2-5
%

Retikulosit

0.0434x106

SGOT

11

0-32 u/L

Coombs test

negative

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

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

PTx

1.1.
1. Co Bed rest
Colorectal
lon O2 nasal canule 2-4
Malignanc
os
L/m
y
co IVFD NaCl rehydration
1,000cc --< 0,9% - 30
1.2.
py
Colitis 2. bio dpm
ulcerati
ps Confirm the diagnosis
and determine the
ve
y
stage

PMo

VS
Subj
ectiv
e
Urin
e
prod
uctio
n
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

2.
2.1 Acute Colono Bed rest
Anemia
blood
scopy Fluid rescucitation with
NaCl 0.9% 1,000cc in
normoc
loss
30min IVFD NaCl
hrome
0.9% 30 DPM
Normoc
yter
PRC transfusion 2
pack/day until Hb > 10
gr/dL

PMo

VS
Subj
ectiv
e
Hb
MCV
MCH
Tran
sfus
sion
react
ion

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
colono
Hypoalb
Hyperc scopy
uminem
ataboli
ia
c state
3.2 Low
intake

PTx

PMo

Diet high calory high

protein 2100 kkal/day

VS
Subj
ectiv
e