case bedah ca sigmoid
TRANSCRIPT
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PRESENTASI KASUS
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IDENTITAS
• Nama : Tn. M
• Usia : 55 tahun
• Pekerjaan : Karyawan• Alamat : Jl.
Sawo• Tanggal masuk : • Tanggal pemeriksaan :
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ANAMNESIS
• Keluhan utama :– BAB berdarah dan berlendir sejak 3 bulan SMRS
• Keluhan tambahan :– Teraba benjolan pada perut sebelah kiri dan terasa
nyeri– Peningkatan frekuensi BAB– Penurunan berat badan
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ANAMNESIS
• Riwayat penyakit sekarang:– Pasien datang dengan keluhan utama BAB yang
berdarah dan berlendir. BAB berdarah sudah dialami pasien sejak 3 bulan SMRS. Darah yang keluar berwarna kemerahan, keluar bersama dengan feses saat defekasi. Pasien tidak mengalami nyeri pada bagian dubur bersamaan dengan keluarnya darah. Jumlah darah yang keluar tidak banyak, hanya berupa bercak-bercak darah.
– Sejak 1 bulan SMRS pasien mengalami frekuensi BAB yang meningkat yaitu sebanyak > 2x per hari, dimana pasien BAB cair dengan darah dan lendir.
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ANAMNESIS
• Riwayat penyakit sekarang:– Pasien juga mengeluhkan adanya rasa tidak
nyaman pada perut bagian kiri bawah. – Pasien mengalami penurunan berat badan,
sebanyak 10 kg dalam 3 bulan terakhir– Pasien tidak mengeluhkan adanya muntah.
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ANAMNESIS
• Riwayat Penyakit Dahulu:– Riwayat gangguan BAB
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ANAMNESIS
• Riwayat kebiasaan:– Konsumsi minuman beralkohol (-)
• Riwayat Keluarga :– Riwayat kanker
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PEMERIKSAAN FISIK
• Keadaan umum : Tampak sakit sedang• Kesadaran : Compos mentis• Tekanan darah : 130/90 mmHg• Nadi : 84x/menit• Laju pernafasan : 20x/menit• Suhu : 36.7 °C
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PEMERIKSAAN FISIK
• Kepala– Mata : KA -/-, SI -/-– Hidung : Deviasi -– Mulut : Mukosa oral basah
• Leher– Pembesaran KGB -
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PEMERIKSAAN FISIK
• Thorax Paru– I : Simetris pergerakan nafas statis dan
dinamis– P : Simetris pergerakan nafas status dan
dinamis, fremitus taktil simetris– P : Sonor +/+– A : Bunyi nafas vesikular +/+, Rhonki -/-,
wheezing -/-
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PEMERIKSAAN FISIK
• Thorax Jantung– I : Ictus cordis tidak terlihat– P : Ictus cordis teraba pada ICS V Linea
midclavicularis sinistra– P :
• Batas atas : ICS III• Batas kanan : ICS V Linea sternalis dextra• Batas kiri : ICS V Linea midclavicularis sinistra
– A : Bunyi jantung I dan II regular, gallop -, murmur -
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PEMERIKSAAN FISIK
• Abdomen– I : Tampak datar– P : Timpani +– P : Supel +, Nyeri tekan –, teraba massa pada regio
LLQ – A : BU (+), 8x/menit
• Ekstremitas– CRT<2 detik– Akral hangat– Motorik 5+/5+
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PEMERIKSAAN FISIK
• Rectal Toucher
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RESUME
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DIAGNOSA KERJA
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PEMERIKSAAN PENUNJANG
• Pemeriksaan darah lengkap– Hb– Ht– Leukosit– Trombosit– Hitung jenis– LED– Elektrolit
• Pemeriksaan colonoscopy/biopsy
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TATALAKSANA
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PROGNOSIS
• Quo ad vitam : Dubia ad bonam• Quo ad functionam : Dubia ad bonam• Quo ad sanationam : Dubia ad bonam
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PEMBAHASAN
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Rectal Bleeding
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Rectal Bleeding Differential Diagnosis
Small Intestine• Meckel’s diverticulum– Usia dewasa muda, melena tanpa nyeri
• Intussusception– Anak, kolik abdomen, bright red/ mucus stool
• Enteritis– Infeksi/radiasi/Chron’s
• Ischaemic– Severe abdominal pain, syok?
• Tumours
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Rectal Bleeding Differential Diagnosis
Proximal colon• Angiodysplasia
– Elderly, painless, volume besar, fresh + clots• Carcinoma of the Caecum
– Causes anemia
Colon• Polyps/carcinoma
– Ass with change in bowel habit, blood mixed with stool• Diverticular disease
– Spontaneous onset, painless, large volume, fresh blood, history of constipation• Ulcerative colitis
– Blood mixed with mucus, ass with systemic, long history, intermittent course, diarrhea prominent
• Ischaemic colitis– Elderly, severe abd pain, bloody diarrhea, shock later
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Rectal Bleeding Differential Diagnosis
Rectum• Carcinoma• Proctitis• Solitary rectal ulcerAnus• Haemorrhoids• Anal fissure• CA • Crohn’s
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LEFT ILIAC FOSSA SWELLING
• Sigmoid colon– Diverticular mass: tender, ill defined, rubbery hard, non-mobile– Paracolic abscess: acutely tender, ill defined, fluctuant– Carcinoma: hard, craggy, non-tender unless perforated,
immobile, associated with altered bowel habit/obstructive symptoms
• Ovarian/Tubal– Cyst– Neoplasm– Ectopic pregnancy– Salpingo-oophoritis
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