MORNING

IDENTITY

Name : Tn. LP
Age : 60 years old
Sex : male
Adress : Balai Kota Permai street
Occupation : Civil Servant
Admission : April 8th 2019
Doctor in charge : dr. Laode Rabiul Awal, Sp.B-KBD
 Anamnesis (23.30 wita)
 Main complain : left lower abdominal pain
 Anamnesis :
Suffered since 4 month ago
 She had intermitten pain. Pain like stabbed and localized
 Another complain: watery stool since 2 month, blood (-), flatus (+)
 There was history of treatment with IVFD, PPI,
 There was history of disease, susp. Colorectal tumor
 There was no history of childhood
 There were no history of fever, wheight loss
 There was no history of trauma
 PHYSICAL EXAMINATION(13.40)

General Condition : Moderate illness

Compos mentis (GCS 15 E4V5M6),
Good Nourish

Vital Sign
BP : 120/70 mmHg
HR : 74x/minutes, regular, strong
RR : 20x/minutes, regular, symmetric
T : 36,2 ◦C/axillary
VAS : 2/10
 PRESENT STATE
Head : Within Normal Limit
Neck : Within Normal Limit
Face : Within Normal Limit
Chest : Within Normal Limit
Eyes : Within Normal Limit
Abdomen: Localized State
Nose : Within Normal Limit
Upper Limb : Within Normal Limit
Mouth : Within Normal Limit
Lower Limb : Within Normal Limit
Ears : Within Normal Limit
Localized state (lower limb)

Abdominal Region
 Inspection: Distanty(-),
 Auskultasi : Peristaltic (+)
 Palpation : tenderness (+) at epigastrium , Massa at
left inguinal, solid, multiple
 Perkusi : Timpani
 RT: spincter ani tonus (+), smooth mucosa, massa(-),
pain(-) blood(-), feses(-)
CLINICAL FINDING
 PLANNING

 Routine blood test, blood chemistry

 USG abdomen

 CT-scan Abdomen
 LABORATORY FINDING
Parameter Result Reference
Value

WBC 4.95 [10^3/uL] 4,00 – 10,0

HGB 12.5 [g/dL] 12,0 – 16,0
PLT 270 [10^3/uL] 150 - 400

GDS 192 Mg/dl 70-180

SGOT 16 U/l <31

SGPT 10 U/l <31

Tumor colon desendesn menginfitrasi mesenterica dan peritonium viseral
 DIAGNOSIS

Tumor colon desendens

 MANAGEMENT
Pharmacological Non-Pharmacological
• IVFD  Rest
• Analgesic injection  Education (nutrition and hygiene)
• PPI injection

Consult to digestif surgeon

Thank You