Mrs. Nunik, 25 yrs oldAdm : 3-2-2013 20.15 amChief 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 examinationGeneral Status:General condition: alert, karnofsky score 60BP: 110/70 mmHgPR:80x/mntRR :16 x/mntT :36,8 0CConjunctiva 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 fragileGloves: liquid stool (+) , blood (-), mucous (+)

Laboratorium:Hb: 7.3Lek :12.6Tromb: 157SGOT/SGPT: 26/16Ur/Cr: 10/0.5Albumin:2.9

Colon in Loop

Chest X-Ray

WD/ :Susp. Distal Third Rectal Cancer + Recto-vaginal Fistula (T4bNxMx)

Th/ IVFD RlUrethral catheterizationAntibioticBlood transfusion until Hb 10 gr/dlPlan to perform CT Scan and elective colostomy

Thank You

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