Duty Report

Saturday, May 2nd 2015

dr. Ramadhan
Physician in charge:
IA : dr. Regy, dr. Jaja
IB : dr. Daya
II CVCU: dr. Rere
II HCU : dr. Ramadhan
II UGD : dr. Hesti, dr. Yanti
Chief : dr. Saras
Consulan: dr. C. Singgih Wahono, Sp.PD-KR

Summary Of Database:
Mr. Achmadullah / 71 yo / w.26

Chief complaint: black tarry stool

History of present illness:
 Patient suffered from black tarrystool since a month ago. About 3-5 times per
day, about 100-200cc each. Fluid consistency.
 He also suffered from abdominal discomfort since a month ago. He felt
fullness of his somach. He had decrase of appetite since then. Ha ate 3-5
table spoon each meal.
 He had passing urine normally with yellow bright coloured.
 Previously he suffered had examined his complained since amonth ago, to the
Kepanjen hospital. He admitted for 2 weeks. The complain was subsided, but
after home care for a week, the complain appear again. He also ever had
bloody vomiting about 2 years ago. He brought to the RSSA hospital and the
docor had diagnosed him liver disease.

History of past illness:

 This is the 3th hospitalization
 The 1st hospitalization ws 2012. He suffered from bloody vomiting. The doctor
diagnosed him suffered from liver disease. He had performed endoscopy. The
results rupture varices esophagus
 He had diagnosed Dm since 10 years ago. The highest random blood suga
rreach 260. He routinely control at kepanjen hospital

History of family:
 Family history with hypertension and diabetes (+) his brother and sister. Bout
no one had history of liver disease.

History of medication:
 He usually consume the drugs that he got from kepanjen outpatient clinic.
Those are Glikuidon, propranolol and spironolactone

History of privation and social

 He is married, had 2 children. He is teacher pensioner
 Risk factor: blood tranfussion (+) PRC 12 pack and thrombocyte concentrate 8
packs at previous admission, alcohol abuse (-), iv drug user (+), tattoo (-),
multiple partner sexual (-)
Physical Examination:
GA: Looked moderately ill; looked normoweight
GCS 456
BP: 110/80 mmHg, PR: 86 times/minute, regular RR: 20 times/minute T: 36,50C
Head : Pale conjungtiva (-), icteric sclera (-), JVP R+0 cmH20

Chest : spider nevi (+)

Cor : Ictus invisible & palpable at MCL S ICS V sinistra
LHM ~ ictus, heart waist +
RHM: SL dextra
S1, S2 are single without murmur
Pulmo : Symmetric;
sonor sonor V V - - - -
sonor sonor V V Rh - - Wh - -
sonor sonor V V -- - -

Abdomen : soefl, bowel sound (+) normal, mass at left upper quadran, 10x6x5cmm
fixed, no pain.
liverspan 5 cm, spleen schoefnerr 2/8, shifting dullness (-)
Extremity : warm acral (+) edema - -
--
RT melena (-), medianus sulcus flatening, mass (-), smooth surface

Laboratory findings

Lab Value (Normal) Lab Value (Normal)

Leukocyte 4.200 4.700 – 11.300 Natrium 128 136 -145
/µL mmol/L
Haemoglobine 12.0 11,4 - 15,1 g/dl Kalium 3.80 3,5-5,0 mmol/L
PCV 34.7 38 - 42% Chlorida 99 98-106 mmol/L
Trombocyte 48.000 142.000 – RBS 133 < 200 mg/dl
424.000 /µL
MCV 75.1 80-93 fl Ureum 19.9 20-40 mg/dL
MCH 26.0 27-31 pg Creatinine 0.65 <1,2 mg/dL
Eo/Bas/Neu/lim 1.2/0.5/56 0-4/0-1/51- Osm 285-295
f/Mon .2/28.8/13 67/25-33/2-5
.3
SGOT 34 0-32 mU/dL Bil Total - < 1,0 mg/dL
SGPT 31 0-33 mU/dL Bil direct - < 0,25 mg/dL
albumin 2.82 3,5-5,5 g/dL Bil indirect - < 0,75 mg/dL
PPT 27.2 11,5-11,8 HbsAg Positive Data from
INR 2.64 0,8-1,30 previous hospital
APTT 30.10 27,4-28,6 AntiHCV Negative
 Urinalysis
Lab Value Lab
Value
Urinalysis 10 x
SG 1.010 Epithelia 1,0
PH 7.0 Cylinder -
Glucose 1+ Hyaline -
Protein negative Granular -
Keton Negative Leukocyte -
Bilirubin Negative Erythrocyte -
Urobilinogen Negative 40 x
Nitrit Negative Erythrocyte 0,7
Leucocyte Negative Leukocyte 1,3
Blood negative Crystal 126.8
Bacteria

 ECG (May 2nd 2014)

Sinus rhythme with heart rate 80 bpm

Frontal axis : Normal
Horizontal axis : Normal
PR interval : 0,16”
QRS complex : 0,08”
QT interval : 0,36”
Conclusion: Sinus rhythme with heart rate 80 bpm

 CXR (May 2nd 2014)

AP position, enough KV, less inspiration, enough KV
Soft tissue normal and bone: normal
Trachea in the middle
Phrenico-costalis angle dextra and sinistra were sharp
Hemidiaphragm dextra and sinistra were domeshape
Lung D/S: bronchovesicular pattern were normal
Heart: site normal, CTR 45%, normal
Conclusion : aortasclerosis

Cue & clue PL IDx PDx PTx PMo

Mr.achmadulah 1. 1. Melena 1.1 rupture endoscopy Patency airway Subjective
/ 71 yo / w.26 (post) Varices breathing and Vital sign
Anamnesis: oesophagu circulation Melena
s O2 2-4 lpm Bleeding
Physical nasal canule manifestati
examination 1.2 peptic Insert NGT on
Conjungtiva ulcer Gastric lavage
anemic (-) bleeding /8 hours  3
Melena (-) times clear,
start fluid diet
Laboratory 6x200cc via
findings: NGT
Leucoyte 4.200
Hb 12.0 Infus NaCl
Mcv/mch: 0,9% 1000cc
75.1/26 loading,
continued with
Endoscopy infus NaCl
results: 0,9% 20 dpm
2012
Rupture Bolus
variceal octreotide
oesophagus gr (postponed)
i-II 50mcg,
continued with
drip octreotide
50mcg/hour
until bleeding
stop
(insert 3 amp
octreotide
@100mcg in
100 cc NaCl
0,9% -
16.67cc/hour)

Mr.achmadulah 2. 2. Cirrhosis 2.1 post Liver biopsy Peroral: Subjective

/ 71 yo / w.26 hepatis child necrotic Propranolol Vital sign
Anamnesis: pugh B hepatitis B 2x10mg CBC
Black tarry stool infection (postponed) Bleeding
since a month manifestio
ago Spironolactone n
Abdominal 0-100mg-0
discomfort (postponed)
Had diagnosed
liver disease Lactulose
since 2012 (3 3xCII
years ago)
History of Treat hepatitis
bloody vomiting B after stable
condition
Physical
examination
Spider nevi (+)
Liverspan 5 cm
Spleen
schoefner 2/8

Laboratory
findings:
Hb 12.0
Leucocyte
4.200
Plt 48.000
Mcv 75.1
Mch 26
PPT 27.2
INR 2.64
APTT 30.10
Hbsag positive

Endoscopy
results:
2012
Rupture
variceal
oesophagus gr
i-II

Mr.achmadulah 3. 3. Dm type 2 Diet DM 1800 Subjective

/ 71 yo / w.26 kcal/day Vital sign
Anamnesis: FBG
Had diagnosed 2hpppBG
Dm since 10
years ago
Controlled and
consume
glikuidon
Physical
examination
-
Laboratory
findings:
RBS 133

Mr.achmadulah 4. 4. Mass at left 4.1 lipoma Consult to Subjective

/ 71 yo / w.26 upper quadran surgery dept Vital sign
Anamnesis: of abdomen Excision if
Mass at upper needed
left quadran
since 6 years
ago

Physical
examination
Mass at uppler
left quadran
Size
10cmx6cmx5c
m, terfixir, pain
(-)

Laboratory
findings:
-

Mr.achmadulah 5. 5. Urine 5.1 benign Insert urine Subjective

/ 71 yo / w.26 retention prostat catheter Vital sign
Anamnesis: hyperplasia Urine
Urinating Peroral production
problem Terasozine Fluid
Retention urine HCl 1x1 tab balance
Sometime with Ureum
sometime creatine
driblling
Physical
examination
RT: medianus
sulcus flattening

Laboratory
findings:
Ureum 19.9
creatinine 0.65