Gender : Female Race : Chinese Work :Housewife Age : 64 years old Hospital / klinik : Hospital Tuanku Fauziah Tarikh : 12 Julai 2012 Aduan utama - Abdominal pain x2/7 Sejarah penyakit kini - Constipation x2/7 o Prolong difficulty in passing motion for 3 4 months o Inability to completely pass motion - Vomiting x2/7 o Water - Did not pass flatus x2/7 - No blood stain stool, no passing out of mucous - No jaundice - No previous operation - No short of breath (SOB) - No allergic reaction to medication - Patient was admitted 2 weeks ago, colonoscopy done, carcinoma of sigmoid colon cancer
Sejarah penyakit lalu (termasuk alahan ubat) - Nil Sejarah keluarga - Mother had colon cancer - No family history of breast cancer - No family history of endometrial cancer Sejarah sosial - Not working - Staying with husband - Having 4 childrens - Non smoker and non alcoholic KAJIAN SEMULA SISTEM SISTEM TUBUH BADAN Cardiovascular system - Dual rhytm no murmur(DRNM) - No cardiomegaly - No palpitation Respiration system - No wheezing - No crepts - No ronchi Lungs - Air entry bilateral symmetrically clear
Gastrointestinal tract system - Abdominal pain x2/7 - Constipation x3/7 - Vomiting - Bowel sound hyperactive - Distended - Resonant left iliac fossa distended - Shifting dullness ve Nerve system - GCS 15/15 - Pin and cotton test +ve - Tendon hammer test +ve - Plantar reflex test +ve Muscular-skeletal system - No oedema - Pronation, supination, extension, flexion and rotation +ve Endocrine system - No diabetes mellitus - No polyurea Reproductive system - Normal
BAHAGIAN 3 : PEMERIKSAAN FIZIKAL Pemeriksaan am : Stable, alert, conscious Tanda vital : Penilaian kesakitan : 4/10 Suhu badan : 37C Kadar nadi : 74 bpm Berat badan: 55 kg Kadar pernafasan : 20 Ritma nadi : Regular Tekanan darah : 150/86 mmHg Isipadu nadi : Bounding Albumin : 35 g/L
Pemeriksaan Kepala dan Sistem Deria Khas : (termasuk Mulut, Tekak, Telinga, Hidung, Mata dan Leher)
Kepala Inspection - No dandruff - No rashes - No pediculosis - No scar - No tender Palpation - No tender Mata Inspection - No jaundice - No conjunctivitis - No discharge - No cataract Hidung - No epistaxis - No nasal polys - No runny nose
Mulut Inspection - No cleft palate - No cyanosis - No candidiasis - No dehydration Muka Inspection - No moon face - No scar - No flushing - No acne Leher Inspection - No mumps - No rashes - No scar Palpation - No deviated trachea - No thyroid enlargement - No tender
Bahagian dada : Jantung : Inspection - No cardiomegaly Palpation - No palpitation Auscultation - DRNM (lup dup sound present) Paru paru : Inspection - No barrel chest - Air enter bilateral symmetrically Percussion - Resonant - No dullness Auscultation - No wheezing Lungs clear - No crepts - No ronchi - Air enter bilateral symmetry
Bahagian abdomen Inspection - No scar - No rashes - No ascites Palpation - Left iliac fossa distended - Shifting dullness ve Percussion - Resonant Auscultation - Bowel sound present (hyperactive) Bowel sound hyperactive Nerve system Inspection - Glasgow Coma Scale (GCS) 15/15 Palpation - Pin and cotton test +ve - Tendon hammer test +ve - Plantar reflex test +ve
Upper limb and lower limb Inspection - No deformities - No previous amputation - Pronation, supination, extension, flexion and rotation test +ve Palpation - No oedema
Lain lain : (termasuk genitalia, rectum & sebagainya) Inspection - On continuous bladder drainage (CBD) - No dysuria - No polyurea - No haematuria Palpation - Normal - No tenderness of urinary bladder
BAHAGIAN 4 : RINGKASAN PENEMUAN YANG PENTING DAN RELEVAN
- left iliac fossa distended -shifting dullness -ve -resonant
BAHAGIAN 5 : DIAGNOSIS Diagnosis perbezaan - Colorectal cancer BAHAGIAN 6 : PENYIASATAN DAN KEPUTUSAN YANG PENTING DAN RELEVAN Full blood count (FBC) Result Normal range White blood cell 10.8 109/L 4 - 11 Red blod cell 4.1 106/uL 3.8 4.8 Haemoglobin 11.1 g/dL (low) 12 -15 Haematocrit 34.8 (low) 36 46 Mean cell volume 84.5 fL 83 101 Mean cell Hb 26.9 (low) 27 32 MNHC 31.9 g/dL 31.5 34.5 Platelete 208 150 450 Differential : Result Normal range Neutrophils 8.53 103/uL (high) 2.0 7.0 Lymphocytes 1.73 103/uL 1.0 3.0 Monocytes 0.54 103/uL 0.2 1.0 Eosinophils 0.00 103/uL (low) 0.02 0.50 Basophils 0.00 103/uL (low) 0.02 0.10
Liver function test (LFT) Result Normal range Total protein 65 g/L 66 81 Albumin 35 g/L 34 48 Globulin 30 g/L A/G ratio 1.2 Total bilirubin 9.9 umol/L 0 24 ALP 5.8 U/L ALT 14 U/L AST 18 U/L
Renal profile (RP) Result Normal range Sodium 136 mmol/L 135 145 Potassium 3.5 mmol/L 3.3 5.3 Urea 2.6 mmol/L 1.7 8.3 Creatinine 55 mmol/L <97
BAHAGIAN 7 : PENGURUSAN 1. Pengendalian awal a. Keep nil by mouth (KNBM) b. Insert Ryles tube c. Start IVD 4 pine (2 pine normal saline, 2 pine D5) 2. Ubat ubatan (spesifik) a. IV Tramal 50 mg b. Syrup Lactose 15 ml OD 3. Ubat ubatan (simptometik) a. Tablet Paracetamol 1 g QID 4. Penjagaan kejururawatan a. Vital sign monitoring 4 hourly 5. Investigation a. Full Blood Count b. Liver Function Test c. Renal Profile d. Chest X-ray e. Electrocardiogram
BAHAGIAN 8 : NASIHAT YANG RELEVAN KEPADA PESAKIT / PENJAGA 1. Follow drug schedule 2. TCA in SOPD 3. Do not do excessive works on heavy job 4. Takes balance meals 5. Drinks more plain water 6. Do light exercise 7. Do not consume alcohol and smoking 8. Keep on healthy lifestyle
NAMA : SITI NUR AZLINA BINTI ABDUL RAZAK NO. MATRIK : DBMA11 0828 TAHUN : TAHUN 2 SEMESTER 2 KAWASAN PENEMPATAN : WAD PEMBEDAHAN TINGKAT 3, HOSPITAL TUANKU FAUZIAH