MORNING REPORT

Wednesday, March 29th 2017

PHYSICIAN IN CHARGE :
IA : dr. Bunga, dr. Eden, dr. Handy
II CVCU : dr. Indri
II HCU : dr. Norma
II UGD : dr. Rina, dr. Reny
Chief : dr. Somarnam
Consultant : dr. Herwindo Pudjo B., SpPD
Facilitator : dr. Sri Sunarti, SpPD-KGer
 SUMMARY OF DATABASE
Mrs. S/ 49 y.o/ W24A
Chief Complain : Fainting
Medical History
• Patient complained about fainting 3 times a day today, duration less than 5
minutes, started with blurred and darkening vision. She came back to her senses
by herself, no seizure.
• Patient passed blood from her anus since 7 days ago but it got much worse today,
the blood was brownish red, thick, and clotting. Each was ½ glass in volume.
• This past month patient felt that she had difficulty in defecating, it was hard and
small and came out in lumps, and sometimes only mucous that came out.
• She had nausea with no vomiting since 1 day ago, it was accompanied by bloated
sensation. She had abdominal pain since 3 days ago, felt like cramp, in the left
lower quadrant. It was intermittent, and she felt it the most when she wanted to
defecate.
• History of epilepsy was denied. DM was denied. History of HT (+) since 2013
 SUMMARY OF DATABASE
Past Medical History & Medication :
She routinely consumed amlodipin prescribed by her doctor

Life Style :
Smoking (-) , Alcohol (-), Traditional Potion (-). She liked to eat meat and not very often
ate vegetables and fruit

Family Medical History :

Her mother died of old age and her father died of respiratory disease. None of his
family had the same disease
 PHYSICAL EXAMINATION
General appearance looked moderately ill Looked underweight
GCS 456
BP 120/80 mmHg PR 80 bpm, reguler strong RR 20 tpm Tax 36.30C
SaO2 98%
Head Conjuctiva Anemic (-) icteric (-) , cyanosis (-) edema (-)
Neck JVP R +0 cm H20, 300 position
Chest Heart Ictus invisible & palpable at ICS V MCL S, heaves (-) thrill (-) cardiac waist normal,
S1, S2 single, murmur (-) gallop (-)
RHM ~ SL (D), LHM ~ ictus
Lung Symmetric Stem fremitus D = S S S v v Rh - - Wh - -
S S v v - - - -
S S v v -- - -
Abdomen Flat, Bowel Sound (+) , liver span 8cm, traube space tymphanic, shifting dullness
(-), RT: no blood, adequate tonus, no palpable mass
Extremities Warm acral, edema (-)
 LABORATORY FINDINGS
(28-03-2017)

LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 20.270 4.700 – 11.300 /µL Natrium 132 136-145 mmol/L
Haemoglobine 11.10 11,4 - 15,1 g/dl Kalium 4,4 3,5-5,0 mmol/L
PCV 32.90% 38 - 42% Chlorida 106 98-106 mmol/L
Trombocyte 283.000 142.000 – RBS 228 < 200 mg/dl
424.000 /µL
MCV 83.7 80-93 f Ureum 16.60 20-40 mg/dL
MCH 28.20 27-31 pg Creatinine 0,4 <1,2 mg/dL
Eo/Bas/Neu/ 0/0,3/91,3/ 0-4/0-1/51-67/
Limf/Mon 6/2,4 25-33/2-5
SGOT 11 0-32 U/L
Ppt 10,3 60-70 SGPT 10 0-33 U/L
Aptt 25,6 30-40 Albumin 3,8 3,5-5,5
• FL :
• Colour: yellow
• Form: soft
• Elemen (-)
• Epitel (+)
• Leukosit 0-1
• Eritrosit 4-6
• Paracyte (-)
• Food remnants (+)
• Muscle fiber (-)
• Vegetable fiber (+)
• Bacteria (++)
• FOBT T1 T2 (+)
EKG
 ECG (March, 28 2017)th

Sinus rhytm, heart rate 90 bpm

Frontal Axis : Normal
Horizontal Axis : normal
PR interval : 0. 12”
QRS complex : 0. 08”
QT interval : 0. 36”
Conclusion : sinus rhythm, HR 90
CT scan abdomen (March 15 2017_
Interpretation :

• solid lobulated mass in intra luminal rectosigmoid, size

39x36mm, length 80mm,
• Lymph node pre sacral shows with 6,2 mm size
• Hepar: no enlargement,
• Gall bladder: normal size, no thickening
• Pankreas: normal size
• Lien: nomal size, normal contour, homogen parenchimal
density,
• Ren D/S normal size
• VU filled optimally
• Aorta: kalsifikasi (+)
•

Conclusion : - solid mass intraluminal attaching to

rectosigmoid wall without diffusion to perirectal fat
- Aortosklerosis
• Biopsi rectum: well differentiated adeno
carcinoma
• Kolonoskopi: polip adenomatous
 Initial Planning Planning Planning
CUE AND CLUE Problem List
Diagnose Diagnose Therapy monitoring

FEMALE/ 49 YO/ W.24a 1. adeno ca Bedrest S, VS, bleeding

rectum CEA, USG Soft diet 1700 kkal/day
SUBJECTIVE abdomen
-passed blood from her anus today
since 7 days ago
- difficulty in defecating, it was
hard and small and came out in
lumps, and sometimes only
mucous that came out.
- abdominal pain since 3 days
ago, felt like cramp, in the left
lower quadrant.

OBJECTIVE
Physical Examination
Abdomen : fat, soef, BU(+)
normal, tenderness (-)

colonoscopy poli adenomatous

PA well differentiated adeno Ca
ct scan: massa intralumen
attached to rectosigmoid wall,
aortasklerosis, spondilasus
lumbalis
 Problem Initial Planning Planning Planning
CUE AND CLUE List Diagnose Diagnose Therapy monitoring

FEMALE/ 49 YO/ W.24a 2. 2.1 Treat underlying S, VS,

leukositosi reactive disease
SUBJECTIVE s

OBJECTIVE
Physical Examination
WBC 20270
Diff Count
0/0,3/91,3/6/2,4
 Problem Initial Planning Planning Planning
CUE AND CLUE List Diagnose Diagnose Therapy monitoring

FEMALE/ 49 YO/ W.24a 3. 3.1 Confirm diagnosis S, VS,

hyperglice reactive GD 1/2
SUBJECTIVE mia state 3.2 dm
History of DM was type 2
denied.
No classical triad

OBJECTIVE
Physical Examination
gds 228
 Problem Initial Planning Planning Planning
CUE AND CLUE List Diagnose Diagnose Therapy monitoring

FEMALE/ 49 YO/ W.24a 4. ivfd NS 20 dpm SE per 3

hiponatre days
SUBJECTIVE mi
hipoosmol
OBJECTIVE ar
Physical Examination hipovolemi
TD 120/80 mmHg
Pulse 86x/minute
RR 20x/minute
tax 36,6

Laboratory Findings :
Ureum 16.60 mg/dL
Creatinin 0,4 mg/dL
SE 132/4,4/106 mmol/L
gds 228
Osm = 279,4
 Problem Initial Planning Planning Planning
CUE AND CLUE List Diagnose Diagnose Therapy monitoring

FEMALE/ 49 YO/ W.24a 5. 5.1 pud Bedrest S, VS

dyspepsia 5.2 soft diet1700
SUBJECTIVE syndrome gastritis kkal/day
Nausea with bloated erosif Intravena
sensation Lansoprazole
abdominal pain since 3 1x30 mg
days ago, felt like cramp, Intravena
in the left lower Metoclopramide
quadrant. It was 3 x 10 mg
intermittent, and she felt
it the most when she
wanted to defecate.

OBJECTIVE
Physical Examination
Abdomen : fat, soef,
BU(+) normal, tenderness
(-)
 Problem Initial Planning Planning Planning
CUE AND CLUE List Diagnose Diagnose Therapy monitoring

FEMALE/ 49 YO/ W.24a 6. History 6.1 Treat underlying S, VS,

of syncope decrease disease bleeding
SUBJECTIVE of
fainting 3 times a day vascular
today, duration less than resistance
5 minutes, 6.2
passed blood from her decrease
anus since 7 days ago of
cerebral
OBJECTIVE perfusion
Physical Examination
TD 120/80 mmHg
Pulse 86x/minute
RR 20x/minute
tax 36,6
 PROBLEM ANALYSIS

Adeno ca recti

dyspepsia

reactive hemorrhage

leucocytosis hyperglicemia syncope

Risk Factor Analysis
 MANAGEMENT ANALYSIS
PROBLEM THEORY FACTUAL

Surgery
Chemotherapy
Radiation therapy
Targeted therapy ‘
Imunotherapy On This Patient :
Key Message Pathophisiology
Key Message Management
 Key Message Social

• Some people, especially if the cancer is

advanced, might not want to be treated at all.
There are many reasons people might choose
to not get cancer treatment, but it’s important
to talk to your doctors and make that decision.
Remember that even if you choose not to treat
the cancer, you can still get supportive care to
help with pain or other symptoms.
 Condition this morning
• BP 120/80 mmhg
• PR 80x/min
• RR 20X/min
• Tax 36,5
THANK YOU