Summary of Database

Mrs. LS /59 yo/ Mawar ward

Autoanamnesis
Chief Complaint : Pale
History of Present Illness:
- The patient has been pale since 5 days ago. The patient easily feels tired during activities. Complaints of foggy
vision or chest palpitations were denied.
- Stools appear blackish brown since the last 1 month. Defecation every day with soft consistency. History of
gastrointestinal bleeding in September 2023 with complaints of vomiting and black stools. The patient then
underwent endoscopy with the results of varices in the esophagus.
- History of fainting at home about 1 week ago. The patient was admitted to the local hospital with initial Hb 6 and
received 3 bags of PRC transfusion.
- Complaints accompanied by nausea when eating, but can still finish 3/4 of the portion. Drink intake is sufficient.
- The patient was diagnosed with Ca Recti in April 2023 based on the results of an abdominal CT scan. The patient
has routine chemotherapy and is currently undergoing his 12 th cycle.
 Summary of Database
Past Medical History:
- There was no history of diabetes mellitus, hypertension, autoimmune disease
- The patient has a history of allergy to penicillin drugs and those ending in "-gin".

Family History:
There was no history of diabetes mellitus, hypertension, autoimmune history, or malignancy in the family

Social History:
- The patient is a retired elementary school teacher, lives at home with her husband.

Review of System:
Urination in normal limits
 Physical Examination
General appearance Looked moderately ill, higienity well maintained, the Sat O298% Room Air
patient can smile, communicative and cooperative BB : 55 kg | BB : 153 cm | BMI: 23.5 kg/m² (normoweight)
UOP : ±1500 cc /24 hours ~ 1,14 cc/kgBB/hours
GCS : E4V5M6 KS : 90%

BP 100/68 mmHg HR 112 bpm regular strong RR 20 tpm Tax 36.5 oC

Head Conjuctiva Anemic (+), Sclera Icteric (-)
Neck JVP R+ 2cmH20
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : - | - Wheezing : -|-

Sonor | Sonor Vesicular | Vesicular -|-

-|-
Sonor | Sonor Vesicular | Vesicular -|-
- |-
Cardio Ictus invisible, S1 S2 single, regular,
murmur (-) gallop (-)
Abdomen Flat, SC, soefl. BU (+)N Liver span 10 cm

Extremities Edema (-), pale (-), Warm acral, calf pain (-)

RT : TSA firmly clamped, smooth mucosa, NT (-) blackish brown feces (+)
 Laboratory Findings (29/11/2023)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 6.620 4.700 – 11.300 /µL Ureum 42,7 20-40 mg/dL

Hemoglobine 6,1 11,4 - 15,1 g/dl Creatinine 0,56 <1,2 mg/dL

PCV 18,7 38 - 42% eGFR 102

Thrombocyte 58.000 142.000 – 424.000 /µL Natrium 137 136-145 mmol/L

MCV 97.4 80-93 fl Kalium 4,07 3,5-5,0 mmol/L

MCH 31.8 27-31 pg Chlorida 105 98-106 mmol/L

Eo/Bas/Neu/Limf/Mon 2,1/0,2/77,4/13,7/6,6 0-4/0-1/51-67/25-33/2-5 SGOT 22 0-40 U/L

SGPT 21 0-41 U/L

ANC 5.120 2.720-7.530 mm3 AU 4,1

Ca 7,8 Pho 3,4

Chest X-Ray (20/10/2023)
 Chest X-Ray (20/10/2023)
• AP position, symmetric, enough KV, ineduaquate inspiration
• Soft tissue looks thin, bone looks normal
• Trachea in the middle
• Hemidiaphragm D and S was dome-shaped
• Phrenico-costalis angle D and S was sharp
• Pulmo: Vascular pattern was normal, there is no infiltrate
• Cor: site N, size CTR 45%, shape N, aortic elongation (-), aortic calcification (-)

Conclusion:
Cor and pulmo was normal
Electrocardiography (29/11/2023)
 Electrocardiography (29/11/2023)

• Sinus tachycardia, HR 112 bpm

• Frontal Axis : Normal
• Horizontal Axis : Normal
• P wave : 0.08s
• PR interval : 0.12s
• QRS complex : 0.08s
• ST segment : isoelectric
• QT interval : 0.36s
• T wave : 0.08s

Conclusion : Sinus tachycardia HR 112 bpm

 CT Abdomen with Contrast 4/4/2023
- Heterogeneous pelvic cavity mass extends to the left dominant intra-abdomen,
mostly has unclear boundaries with the uterus and sigmoid colon, suspected
Cystoma ovarii malignant effect obliterating the left ureter, causing moderate left
hydroureteronephrosis and delayed left renal function
- Incomplete double system right kidney accompanied by mild hydroureteronephrosis
in the upper and lower moiety EC mass pressure
- Left parailiac lymphadenopathy, malignant impression
- Cholelithiasis without dilation of the biliary system
Rectosigmoid Biopsy 10/04/23
Low Grade Adenocarcinoma
Endoscopy 23/10/2023
- Grade III-IV Esophageal
varices with red whale sign and
cherry red patches
- Grade A LA esophagitis
- Portal Hypertension
Gastropathy with corpuscle
erosion
 Scoring
- Khorana Score: 1 Points (intermediate risk)
- IMPROVE Bleeding Score: 11.5 points (increased risk of bleeding)
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mrs. LS /59 yo/ Mawar ward 1. Adenocarcinoma - - Non Pharmacology PMo :

Subjective Recti Low Grade - S, VS, Chemothreapy
- Diagnosed with Ca Recti in April 2023. Stadium IIIC Reaction, TLS Sign
- Routine chemotherapy and currently T4bN1bM0 Pro Pharmacology
undergoing her 12th cycle. Chemotherapy Chemotherapy Regimen
FOLFOX seri 1 siklus 12/12 PEd :
Objective Explain the patient and
BP : 100/68 mmHg, HR : 106 x/m, RR : family about the
18 x/mnt, SpO2 : 97% RA chemotherapy and its
KS 90% side effects.

CT Abdomen With Contrats :

Heterogeneous pelvic cavity mass
extends to the left dominant intra-
abdomen, mostly has unclear
boundaries with the uterus and sigmoid
colon, suspected Cystoma ovarii
malignant effect obliterating the left
ureter, causing moderate left
hydroureteronephrosis and delayed left
renal function

Biopsy
Adenocarcinoma Low Grade

Khorana Score: 1 Points (intermediate

risk)
IMPROVE Bleeding Score: 11.5 points
(increased risk of bleeding)
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mrs. LS /59 yo/ Mawar ward 2. UGIB 2.1 Variceal Bleeding dt - Non Pharmacology PMo :
Rupture VE Endoscopy - Interim fasting, NGT S, VS, melena
Subjective 2.2 Non Variceal inserted, GC /8 hours, 2x
2.2.1 SRMD clean start liquid diet 6x50-
- Blackish brown stools since last 1 2.2.2 Related to 100cc PEd :
month. Trombocytopenia - IVFD Bfluid: D10% 2:1 Explain the patient and
- History of gastrointestinal 1500cc/24 hours family about the UGIB
bleeding in September 2023 with can be caused by the
complaints of vomiting and black Pharmacology variceal rupture due to
stools. - IV Lansoprazole 2x30 mg varicee rutpture based
- Had underwent endoscopy with - PO Propanolol 3x20 mg on current endoscopy
the results of varices in the - PO Spironololactone 1x100 results or another
esophagus. mg cause such as SMRD
or Trombocytopenia
Objective
- BP : 100/68 mmHg, HR : 112 x/m,
RR : 18 x/mnt, SpO2 : 97% RA
Conjuctiva Anemic (+)
RT : blackish brown feces (+)

Laboratory
CBC 6,1 / 6.620/18,7/ 58.000
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mrs. LS /59 yo/ Mawar ward
Subjective
- History of fainting at home about
1 week ago. The patient was
admitted to the local hospital with
initial Hb 6 and received 3 bags of
PRC transfusion.
- Blackish brown stools since last 1
month.
Objective
Conjuctiva Anemic (+)
RT : blackish brown feces (+)
Laboratory
CBC 6,1 / 6.620/18,7/ 58.000
3. Anemia NN 3.1 Chronic Blood Loss - Non Pharmacology PMo :
3.2 Related to Malignancy Reticulocyte - Bedrest S, VS, bleeding signs,
, FOBT - Pro PRC transfusion 2 transfusion reaction,
flasks/day with total
requirement ~780cc CBC post-transfusion
Pharmacology PEd :
- - Explain the patient
and family about the
anemic condition can
be caused by blood
loss from stools or can
be relate with the
malignancy.
- Explain about the pla
for transfusion before
starting chemotherapy
 Problem Analysis
Risk Factors
(Age, lifestyle, Environment)

Malignancy Process

Colorectal malignancy

Chemotherapy
Anemia NN

UGIB

Variceal Non Variceal

 Risk Factors Analysis
PROBLEM THEORY FACTUAL
Carsinoma 1. Men > Women Women
colorectal 2. FAP ( Familyal adenopamtosis 41 years old
polyposis) polyp at young aged
3. HNPCC (Herediter nonpolyposis
herediter colorectal cancer)
4. Inflamatory bowel disease
5. Smoking
6. Diabetes melitus
7. Obesity
8. 90% cases aged 50 yo

Pocket medicine 4Th Sabatine

Key Message Pathophysiology
Key Message Diagnosis
Key Message Management
Risk Factors Analysis
 Risk Factors Analysis
Problem Theory Patient

Melena
• Varices Esophageal

• Starr et al. 2011. Cirrhosis: Diagnosis,

Management, and Prevention. Am Fam
Physician. 2011 Dec 15;84(12):1353-1359.
• National consensus on management of non-
variceal upper gastrointestinal tract bleeding in
Indonesia
Key of Pathophysiology
 Key Message Social
• Patient must be educated for following the Chemotherapy schedul
• Stabilization of patient’s condition is the major priority. Stop the bleeding, and give sufficient fluid.
• Endoscopy should be done immediately if the patient has been stabilized, to confirm the diagnose
(knowing the source of the bleeding), and do the endoscopic management if possible.
• Stop using the agent that is causing the bleeding if possible or if not possible, change the agent
that is causing the bleeding with a safer drug.
• Support from the family, and patience is needed to follow the therapy
 Condition This Morning

GA: Look mild ill,neated, good personal hygiene, good mood,

smiling while visited and looked active and talkative

GCS : 456 compos mentis

BP : 113/76 mmHg
PR : 88 bpm
RR : 20 tpm
Temp : 36,2 oC