CASE BASE DISCUSSION

PER RECTAL PAIN

Prepared by : Muhammad Nuzul Alimi Bin
Mohd Daud
PATIENT’S DETAILS
• Patient name : Jusoh bin Kassim
• Age : 67 years old
• RN no : 1088704
• Gender : male
• Race : Malay
• Occupation : Not working, retired labourer
• Address : Batu 6 Kuantan, Pahang.
• Marital status : Married
• Date of admission : 10/7/2018
• Date of clerking : 10/7/2018
Chief complaint
• Per rectal bleeding 2 days prior to admission .
History of presenting illness
2 days prior to admission
• He was in normal state of health until 2 days prior to admission he
developed per rectal bleeding noticed by him during defecation 3
times in a day. It occur before and after defaecation. The bleeding was
fresh blood and small amount of blood clot. The amount was about 3
tablespoon. The stool mixed with brown stool mucus. He also
experienced tenesmus.
HOPI
One day prior to admission:
• He developed intermittent moderate per rectal pain. The pain was colicky, not relieved during
rest, increase during sitting and moving, not radiate. The pain make him felt so uncomfortable to
move.
• The rectal bleeding was still remain
• The condition worsened when he become lethargy and his wife noted that he looks pallor
• Her wife immediately brought him to the HTAA.
• He has loss of appetite for one month before. His family noticed he become thinner but no weight
measured.
• No abdominal pain.
• No altered bowel habit.
• No constipation.
• No hematemesis
• No nausea and vomiting.
• No fever
At HTAA some investigation were done:
• Baseline blood test (FBC, LFT, RP, UFEME,BUSE)
• His Hb was 6.3 and he was given 1 pint blood transfusion.
• He looked dehydrated and gave IVD
• Proctoscope were done and some blood clot seen. PR done no
fissure.
• Colonoscopy was done revealed solitary rectal ulcer
• On the day of clerking the symptoms improved.
Past medical history
• He had diagnosed DM 7 years ago with insulin treatment. His DM was
not well control which the latest RBS was 26.9mmol/L.
He also having complication of DM such as blurring of vision.
• Hypertension : 7 years ago. On medication. Well controlled.
• Hyperlipidaemia on medication.
Past surgical history
• No past surgical history.

Drug and allergy history.

• Sc actrapid 5u TDS
• Sc insulated 14u ON
• T. Atorvastatin 40 mg ON
Family history

He is the eldest out of 3 siblings. Her sisters were 58y/o and 52y/o His
parents were died. He did not know the cause.
His siblings were medically fit
No history of same illness in the family
No history of malignancies.
Social history
• He is a retired labour who lives with his wife at Batu 6 Kuantan
• His wife 51 years old healthy and no medical illness.
• Blessed with 8 children (3 male, 5 female) and all are healthy.
• Total income: RM 2000 , from the first three children .
• He stay at single storey terrace house with her family with good
sanitation and facilities.
• He is non-smoker, not alcoholic or drug abuser.
Physical examination
GENERAL INSPECTION
• thin build
• Old age gentleman, lying comfortably in supine position during the
examination.
• Patient was alert, conscious, cooperative and not in distress.
• Branula attached at right dorsum, to a running normal saline.
GENERAL EXAMINATION
• Hand: mild pallor, however other periphery findings were negative that is
capillary refill time (CRT) was 1 to 2 seconds, clubbing nails, palmar
erythema, Dupuytren’s contracture, koilonychia, leukonychia, flapping
tremors, stretch marks or tattoos.
• Head and Face: There was subconjunctival pallor, no sclerotic jaundice,
facial puffiness, angular stomatitis, ulcer and central cyanosis.
• Thyroid and Lymph Nodes: No neck enlargement and no lymphadenopathy.
• No pitting edema noted on both legs.
vital signs:
• Temperature : 37°C (afebrile)
• Respiratory rate : 20 breaths per minute
• Blood pressure : 144/77 mmHg
• Pulse rate : 86 beats per minute, regular and good volume.
Abdominal examination
• On inspection, the abdomen was symmetrical in shape and moves with
respiration. The umbilicus was centrally located and inverted. There were no
spider naevi, caput medusa, and the axillary hair was normal. There was no
visible pulsation or visible peristalsis. There were no scratch marks and striae.
• On light palpation, the abdomen was soft and non-tender. On deep palpation, no
palpable mass noted, the liver was not enlarged. Spleen was not enlarged and the
kidney was not ballotable. There were no sacral edema.
• On percussion, the abdomen was resonance. The traube’s space was resonant.
There was no ascites as the shifting dullness and fluid thrill was negative.
• On auscultation, bowel sound was present. There were no renal and aortic bruit.
Per rectal examination
• Was not done.
Summary
• A 67 years old Malay male, with underlying DM,HPT and Dyslipidemia
admitted to HTAA with the chief complaint of per rectal bleeding 2
days prior to admission. He also developed per rectal pain, LOA,LOW
lethargy and tenesmus. Otherwise he denied any abdominal pain,
altered bowel habit, constipation, hematemesis, nausea and vomiting
and fever. No same illness in the family and no history of malignancies
in the family. He is non smoker. On PE , he had mild pallor of palm and
conjunctiva. Otherwise no positive finding in PE.
Provisional diagnosis
1. Solitary rectal ulcer
Point support:
• Rectal bleeding
• Rectal pain
• Tenesmus
• Passing mucus
• Anemia
Differential diagnosis.
2. Rectal ca:
Points support:
• Rectal bleeding
• Tenesmus
• LOA, LOW
• Rectal pain

Points against :
• No family history of malignancies.
• Do not changed bowel habits
Investigation
BASELINE
1) Full blood count – heamoglobin level (8.2g/dL), WBC count (TWBC 13.24) , platelets ( 412)
2) Liver function test – assess the liver function
3) BUSE – electrolyte imbalances
4) Renal function test
5) Tumor Marker
6) Blood sugar profile- DM
7) Coagulation profile
Diagnostic
1) Colonoscopy
2) Ct scan abd/ pelvis
3) Biopsy
Management plan
• give IVD
• Continue blood transfusion until Hb improve.
• Give antibiotic iv cefuroxime 750mg TDS
• Keep monitoring.