Friday 4-5-2018 Hematochezia

Dr.
Jefri
MORNING REPORT
Date : 4th May 2018
Physician in charge
I : dr. Jefri, dr. Fredo, dr. Ikke, dr. Dewi
II CVCU : dr. Roni
II HCU : dr. Mirza
II UGD : dr. Rima, dr. Tio
Chief on duty : dr. Regy
Consultant on duty : dr. Didi Candradikusuma, SpPD-KPTI
Facilitator : Prof. Dr. dr. Handono Kalim, SpPD-KR
Summary of Database
Mr. MJ/34 yo/ward 23I
Autoanamnesa
Chief Complaint: Bloody stools
History of Present Illness:
Patient complained about bloody stool since 1 day before admission. It was bright red
color, with liquid to soft consistency, frequency 4 times, with the total volume about 400 cc.
He said sometimes stools were accompanied with black clot. This was the second times he got
this complaint, the first time about 2 months ago.
At first he complained about stomachache since 7 months ago. He already went to the
doctor and was diagnosed as. “sakit maag”. He got treated and got better but only for a while.
The complaint came again, and since 2 months ago, he started to complain about bloody
stools.
He also said that he had change of bowel habit. Sometimes it was diarrhea and
sometimes it was normal. He never experienced any small size defecation. He said his
bodyweight was decreased 14 kg in 7 months.
Summary of Database
Past Medical History:
1 week he had just got out of RSSA due to same condition.
Family History:
There was no family member with malignancy or same condition that he had.
Social History:
He didn’t drink any alcohol nor drink traditional potion. He had a wife and 1 child. He was
working as a vegetable merchant.
Review of System:
Urination was normal
Physical Examination
General appearance look mildly ill Sat O2 98% room air
GCS 456 VAS 0/10
BP 130/70mmHg PR 70 bpm regular strong RR 18tpm Tax 35.6oC
Head Conjuctiva Anemic (+)
Neck JVP R+ 1 cmH20
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : - | - Wheezing : -|-
Sonor | Sonor Vesicular | Vesicular -
|- -|-
Sonor | Sonor Vesicular | Vesicular -
|- - |-
Cardio Ictus invisible, palpable at MCL (S) ICS V
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) normal, shifting dullness (-)
Liver/ unpalpable, liver span 10 cm, epigastrium tenderness (-)
Lien/ Traube space tymphany.
Extremities Edema (-), pale (-), MMT 5 | 5 ,
5|5
RT Tonus sphincter ani (+); mucous slippery soft; melena (-); hematoschezia (+)
Laboratory Findings (3/5/2018)
LAB VALUE NORMAL
Leucocyte 7.140 4.700 – 11.300 /µL
Hemoglobine 10.6 11,4 - 15,1 g/dl
PCV 33.3 38 - 42%
Thrombocyte 594.000 142.000 – 424.000 /µL
MCV 71.9 80-93 fl
MCH 22.9 27-31 pg
Eo/Bas/Neu/ 4.5/1.0/60.9/ 0-4/0-1/51-67/

Limf/Mon 27.2/6.4 25-33/2-5
SGOT 10 0-40 U/L
SGPT 8 0-41 U/L
PPT 10.7 (10.9) 9.3-11.4 detik
APTT 27.6 (25.1) 24.8-34.4
INR 1.03 0.8-1.30

Electrocardiography (4/5/2018)
Electrocardiography (4/5/2018)
• Sinus rhythm, HR 75 bpm

• Frontal Axis : Normal
• Horizontal Axis : CCWR
• P Wave : Normal
• PR interval : 0.16 second
• Q wave : Normal
• QRS complex : 0.08 second
• QT interval : 0.36 second
• ST Segment : Isoelectric
• T Wave : Inverted in V1-V2
• Other Abnormality: Coronary (-), Chamber (-) Conduction (-)
Conclusion : Sinus Rhythm with HR 75 bpm

Chest X-Ray (19/4/2018)
Chest X-Ray (19/4/2018)
• AP position, symmetric, enough KV, enough inspiration
• Soft tissue was thin and bone was normal
• Trachea in the middle
• Hemidiaphragm D and S was dome-shaped
• Phrenico-costalis angle D and S was sharp
• Pulmo: bronchovesicular pattern was normal
• Cor: site N, size CTR 55%, shape N, elongation aorta (-), cardiac
waist (+)
Conclusion: normal chest x-ray

POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
1. Hematochezia 1.1Internal Colonoscopy Non-Pharmacology Pmo
Mr MJ/34 yo/ward 23I
Hemorrhoid gr Bed rest S, VS
1 Liquid diet 6x200cc
Subjective
1.2 Pharmacology P-Edu
Bloody stool since 1 days Diverticulosis IVFD NS 30 tpm Educate
ago 1.3 Colitis PO 3xC patient to
Decreased of body weight
1.4 Ca colon take more
Change of bowel habit water
History of diarrhea
intake, eat
vegetables,
Objective less oily
BP 130/70mmHG
food.
HR 75 bpm
RR 18 tpm
Conjunctiva anemic
NGT inserted  clean
RT: hematochezia (+), soft
and chewy consistency.
Laboratory
Hb 10.6 gr/dl
MCV/MCH 71.9/22.9
WBC 7.140/uL
POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
2. Anemia HM - - Non-Pharmacology Pmo
Mr MJ/34 yo/ward 23I
dt chronic bed rest S, VS
blood loss IVFD NS 30 tpm
Subjective
Liquid diet 6x200cc P-Edu
Bloody stool Pharmacology Educate
Objective - patient to
eat iron rich
Conjunctiva anemic food
Laboratory
HB 10.6
MCV/MCH 71.9/22.9
Problem Analysis
Diverticulosis Hemoroid Interna Colitis Ca Colon
Hematochezia
Chronic Blood loss
Anemia HM
Key Message Pathophysiology
• LGIB refers to blood loss of recent onset originating

from a site distal to the ligament of Treitz
Key Message Diagnosis
Clinical Manifestation
• Bright red color stools usually come from colon
acendens
• Dark red color stool usually come from colon
decendens.
Management Analysis
Problem Theory Patient

Hematochezia Fluid resuscitation Non-Pharmacology
Blood transfusion bed rest
Liquid diet 6x200cc
Pharmacology
IVFD NS 30 tpm
Key Message Social
• Educate patient to eat liquid food in small portion

• Educate to eat more vegetables, high fiber diet, and
less oily foods.
Condition This Morning
• GCS 456
• BP: 120/70mmHG
• HR: 73 bpm
• RR 18 tpm
Prognosis
• Ad vitam : bonam
• Ad functionam : bonam
• Ad sanationam : bonam

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Dr.

Leucocyte 7.140 4.700 – 11.300 /µL

Hemoglobine 10.6 11,4 - 15,1 g/dl

PCV 33.3 38 - 42%

Thrombocyte 594.000 142.000 – 424.000 /µL

MCV 71.9 80-93 fl

MCH 22.9 27-31 pg

Eo/Bas/Neu/ 4.5/1.0/60.9/ 0-4/0-1/51-67/

SGOT 10 0-40 U/L

SGPT 8 0-41 U/L

PPT 10.7 (10.9) 9.3-11.4 detik

APTT 27.6 (25.1) 24.8-34.4

INR 1.03 0.8-1.30

• Sinus rhythm, HR 75 bpm

Conclusion : Sinus Rhythm with HR 75 bpm

Conclusion: normal chest x-ray

Diverticulosis Hemoroid Interna Colitis Ca Colon

Chronic Blood loss

• LGIB refers to blood loss of recent onset originating

Problem Theory Patient

• Educate patient to eat liquid food in small portion

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