Mrs.

Nunik, 25 yrs old

Adm : 3-2-2013 20.15 am
Chief Compliant : stools came out from vagina
History Taking :
2 weeks before admission, patients complain stools that came
out through vagina. These was preceded by changes in stools
caliber (diarrhea), and sometimes bloody and mucoid stools
about 6 months before admission. Patient also complaint
weakness, and anorexia, but there was no significant loss of
body weight. There was no history of abdominal pain, bloating,
nausea and vomiting. There is no family history with the same
complaint or any others malignancy disease. Because of the
complaint, patient was brought to Sampit Hospital, and was
transfused (Hb 2,5gr/dl), and then patient was referred to Ulin
Hospital.
Physical examination
General Status:
General condition: alert, karnofsky score 60
BP : 110/70 mmHg PR : 80x/mnt

RR : 16 x/mnt T : 36,8
0
C
Conjunctiva was anemic, sclera wasnt icteric

Local Status:
At abdomen : soft, distention (-), normal bowel sound, metalic
sound (-), tenderness (-), rebound tenderness(-),
bowel contour and movement (-)
DRE : normal sphincter tone, rectal vault wasnt
collapsed, mass (+) 1cm from anal verge, bumpy,
not fragile
Gloves : liquid stool (+) , blood (-), mucous (+)
Laboratorium:
Hb : 7.3
Lek :12.6
Tromb : 157
SGOT/SGPT : 26/16
Ur/Cr : 10/0.5
Albumin :2.9

Colon in Loop
Chest X-Ray
WD/ :
Susp. Distal Third Rectal Cancer + Recto-vaginal Fistula
(T4bNxMx)

Th/
IVFD Rl
Urethral catheterization
Antibiotic
Blood transfusion until Hb 10 gr/dl
Plan to perform CT Scan and elective colostomy


Thank You