BAHAGIAN 1 : BUTIR BUTIR PERIBADI PESAKIT

Register number : 17568/12

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

Chest x-ray
- Lungs clear
Electrocardiogram (ECG)
- Sinus rhythm



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