geriatry with poor intake and fistula recto vaginal must be caution for infection spreading without significant clinical symptom

1. DUTY REPORT
3rd February 2016
Ca Cervix stadium IV
residif with fistula rectovagina and bone metastatic with
geriatry infection perspective
Resident on duty : dr. Shiddiq & dr. Agil
Coass on duty : Giavanny & Nima
Supervisor : dr Soroy Lardo SpPD FINASIM
Divisi /Sub SMF Penyakit Tropik dan Infeksi
Indonesia Army Central Hospital Gatot Soebroto

2. PATIENT’S IDENTITY
• Name : AU
• Sex : Female
• Place, Date of Birth : 10th April 1943
• Age : 73 years old
• Occupation : Housewife
• Religion : Moslem
• Marital Status : Married
• Address : Jl. H. Awaludin II
• Date of admission : 3rdFebruary 2016

3. Chief complaint : smelly discharge from vaginal and
rectal for approximately 1 month
Additional complaint : nausea and weakness
3

4. History of Present Illness
History of Present Illness :
Patient came to the ward with chief complaint of smelly discharge
from vagina and rectal for ± 1 month.
1 year before admission, she complained smelly vaginal and rectal
discharge, then she came to primary health care and felt better.
But 2 weeks later she reported the same complaint.
4 months before admission, she came to RSAL Mintoharjo with
the same complaint as before and the doctor told her there was a
hole between her vagina and rectal. Then she reffered to RSPAD
Gatot Subroto
Before the complaint of smelly discharge from vagina and rectal,
she also had a vaginal bleeding.

5. Because of the smelly discharge she had a decrease appetite
she also reported nausea and vomit, abdominal discomfort (+),
weakness (+), she can not walk and just lied on the bed. Weight
loss (+) ± 10 kg within 4 months.
Patient did not have a history of fever, no sore throat, no cough,
and no symptoms of flu, no history of heavy breathing, no history
of chest pain. No complaint of urinate and defecate
*The patient treated by internal medicine department, obsgyn and
surgery department

6. History of Past Illness
She diagnosed with Ca Cervix since she was 48 years old and
had radiotherapy and chemotherapy
DM (-)
HT (-)
Kidney disease (-)
Lung disease (-)

7. History of family illness
• No history of Ca Cervix
• No family members have the similar symptoms

8. History of Socio-Habits
• She neither smokes, drinks alcohol, nor uses any
forbidden drug

9. Physical Examination
• General State : Mildly sick
• Consciousness : Fully alert
Vital Signs
• Blood Pressure : 90/70 mmHg
• Heart rate : 86 bpm (regular)
• Respiratory Rate : 20 times/minute
• Temperature : 37,1 oC
• Body Weight : 45 kg
• Body Height : 156 cm
• BMI : 18.49 (Normoweight)

10. General Examination
•Head : Normocephal
Eye : anemic conjunctiva (-/-), icteric sclera (-/-)
Ears : discharge (-)
Nose : septum deviation (-), discharge (-)
Mouth : coated tongue (-), hyperemic pharynx (-), normal T1-T1,
pale mouth mucosa (-), dried mucosa (-)
•Neck : lymph nodes enlargement (-)

11. •Thorax: symmetric, intercostals retraction (-)
COR
Inspection: Ictus cordis (-)
Palpation: heave (-), lift (-), thrill (-)
Percussion:
Right border: ICS V, linea midclavicularis dextra
Left border : ICS V, linea midclavicularis sinistra
Heart waist: ICS IV, linea parasternal sinistra
Auscultation : regular 1st and 2nd heart sound, murmur (-),
gallop (-)

12. ▫ PULMO
• Inspection : chest within normal shape, symmetries on static and
dynamic state
• Palpation : tactile vocal fremitus both lungs were symmetries, chest
expansion symmetries
• Percussion : resonant both lungs
• Auscultation : vesicular breathing sounds, rales (-/-), wheezing (-/-)
• Abdomen : flat, not distended
timpani, no enlargement of liver & spleen, pain tenderness (-)
• Urogenital : no examination (patient refused).
• Extremities : CRT < 2 seconds, lower limb athropy (+)

13. Laboratory Results
RESULT Nilai Rujukan
27/01/2016
Hemoglobin 12.7 12-16 g/dL
Hematokrit 39 37-47 %
Eritrosit 4.3 4,3-6,0 juta/μL
Leukosit 18670 4.800-10.800/μL
Trombosit 211000 150.000-
400.000/μL
MCV 90 80-96 fL
MCH 27 27-32 pg
MCHC 33 32-36 g/dL

14. Jenis
Pemeriksaan
Hasil Nilai Rujukan
26/01/2016
PT Control = 11.0
Patient = 10.5 9.3 – 11.8 sec
APTT Control = 33.1
Patient = 31.0 31 – 47 sec
SGOT 36 < 35 U/L
SGPT 14 < 40 U/L
Albumin 2.4 3.5 – 5.0 g/dL
Ureum 67 20 – 50 mg/dL
Creatinin 1.5 0.5 – 1.5 mg/dL
GDP 92 70 – 100 mg/dL
GD2PP 124 < 140 mg/dL
Natrium 131 135 – 147 mmol/L
Kalium 4.7 3.5 – 5.0 mmol/L
Clorida 97 95 – 105 mmol/L

15. • Radiology Result (18th January 2016)
▫ Conclusion : Fistel Rectovagina

16. RESUME
Mrs. AU, 73 years old, came to ward with the chief complaint of smelly
discharge from vaginal and rectal for ± 1 year and heavier for 1 month
before admission. Because of the smell she loss her appetite, nausea and
vomit (+), and weight loss ± 10 kg within 4 months.
There was a history of Ca Cervix and she had radiotherapy and
chemotherapy
Physical examination: atrophy lower limb
Laboratory results showed Leukocytosis (18670), elevated SGOT (36),
hipoalbuminemia (2.4), hiponatremia : 131, ureum (67)

17. Diagnosis
• Working diagnosis
• Ca Cervix IV residif with fistula rectovagina
and bone metastatic
• Poor intake on geriatry

18. List of Problem
• Ca Cervix IVresidif with fistula rectovagina and
bone metastatic
• Poor intake on geriatry

19. Discussion
• Ca Cervix IV residif with fistula rectovagina and bone metastatic
▫ From anamnesis
▫ A history of Ca cervix and had rectovaginal smelly discharge
▫ Weight loss 10 kg within 4 months
▫ Lab result: Leucocytosis
▫ From Radiography
● Fistula rectovagina  sign of bone metastatic
Planning therapy:
IVFD NaCl 0.9% 500 cc/6 hours
Cefotaxim 3x1 gram IV
Vitamin C 2x1 amp
Paracetamol 3x500 mg prn
Surgery  from surgery department

20. • Poor Intake on Geriatry
• Anamnesis:
▫ Loss of appetite
▫ Nausea, vomiting, weakness, weight loss 10 kg
within 4 months
• PE
▫ BMI 18.49  if there is no treatment she will fall
to underweight
• Planning therapy
▫ Diet 1700 kkal
▫ Ranitidin 2x50 mg IV
▫ Ondancentron 3x4 mg IV
▫ Education: eating small but frequent
▫ NGT  if the patient refuse to take her meal

21. Prognosis
• Quo ad Vitam : dubia
• Quo ad Functionam : ad malam
• Quo ad Sanationam : ad malam

22. Infection
Perspective
Ca cervix 75 y.o
Cancer
Chronic inflammation Decrease condition
Innate Humoral immunity
Infection Colonization
Abnormality
coagulation
Sepsis
Poor intake

23. Additional discussion
• In this patient with ca cervix have a decrease
condition, because of chronic inflammation from
the cancer.
• Complaint of poor intake association with smelly
discharge from her rectovaginal makes her
condition more decrease  she complained
general weakness and unable to walk.
• This condition makes her more easy to having
infection which leads her to sepsis.

24. • Sepsis itself is very dangerous, especially she is a
geriatric patient. So we need to look more
carefully for her proper treatment
• 1st step, we can correct her diet. If she can not
take her meal properly, we should use NGT to
maintain her diet.
• We hope with proper diet, her complaint such as
vomit, nausea, abdominal discomfort and also
general weakness can be resolved

25. THANK YOU