Mr 17042015 Ipd Rudi

Morning ReportApril 17th 2015

Coass in charge :Cristian RajagukgukRudi Rakhmad H

Supervisor :dr. Laksmi S, SpPD-KEMD

Summary of Data BaseMr. J / 45 years old / Ward 26

HISTORY TAKING : autoanamnesis and heteroanamnesis with his wife

CHIEF COMPLAINT : coffe ground vomitting and Black tarry stool

HISTORY OF PRESENT ILLNESS

Patient presented with bloody vomitting since 1 week before admission. He vomitting 2-3 times a day, volume ½ of glass each vomit, contain residual food and liquid with coffee ground colour. Patient also often complained about epigastric pain if he want to vomit, the pain was not reffered to other place.

Patient also complained about black tarry stool since a week before admission, he passing stool 2 times a day with voume ¼ of glass, there was no pain accompanied when he passing stool. Patient also complained about abdominal discomfort that make him lost his appetite. He only ate porridge 2 -3 table spoon a day.

He complained abdominal enlargement since 2 weeks before

admission, accompanied with shortness of breath and leg swelling.

Shorthness of breath not related with activities.

He had been diagnosed liver chirrosis since 6 years ago. He was

admitted at RSUD Pare because of the same illness. He didn’t routine

controlled his disease.

Family history : -

Pass medical history: -

Social history: he is married, having 1 children, history IDU (-),

multipartner sexual (-), consumption alcohol (-)

Physical ExaminationGeneral Appearance: looked moderately ill Looked normoweight BMI

GCS: 456 BP : 120/70 HR : 88 bpm regular strong

RR : 24 tpm Tax : 36,6 °C

Head Anemic conjunctiva (+) , icteric sclerae (-), looked normocephal

Neck JVP: R + 0 cm H2O in 30° position ; Lymphnode enlargement -

Chest

Wall Chest expansion symmetric.

HeartIctus invisible, palpable at ICS V MCL S Trill: - Heaves: -RHM ~ SL D LHM ~ ictusS1 and S2 single, murmur (-), gallop (-)

Lung

Stem Fremitus D=S S S BS v v Rh - - Wh - - S S v v - - - - D D - - - -Percussion : dullness lower part of lung D S

AbdomenDistended,bowel sound normal, liver span 7 cm, shifting dullness(+), traube space (+)

ExtremitiesWarm acral, Bilateral leg edema, RT melena (+)UOP 20cc/hour

Lab Value Lab Value

Leukocyte 24.700 4.700-11.300/µL Natrium 129 136-145 mmol / LHaemoglobine 7,20 11,4-15,1 g/dl Kalium 4,40 3,5-5,0 mmol / L

MCV 87,10 80-93 fL Chlorida 111 98-106 mmol / LMCH 31,50 27-31 pg RBS 119 < 200 mg/dLHaematocrit 23,10% 38-42% Ureum 118,2 16,6-48,5 mg/dL

Trombocyte 33.000 142.000-424.000/µL

Creatinine 2,21 < 1,2 mg/dL

BUN 15.59Eo/Ba/Neu/Ly/Mo 0.4/0.4/73,3/

16,6/9,30.4/0.1/51-67/25-33/2-5

Osmolarity 268 280-295

SGOT 38 0-32 U/L Albumin 1,92 3,5-5,5 g/dLSGPT 15 0-33 U/L PPT 11,6 9,3-11,4

aPTT 30,50 24,8-34,4

LABORATORY RESULTS| April 17th 2015

Lab Value Lab Value

Faal Hati Chemical• Protein total 0,61 g/dL <3 g/dL

Billirubin total 0,80 <1,0 mg/dL • Glucose 122mg/dL >60 mg/dL

Billirubin direct 0,56 <0,25mg/dL • Trigliceryde 7

Billirubin indirect 0,24 <0,75 mg/dL • Choleterol 9

Protein total 4,23 6,7-8,7 g/dL • LDH 50

Albumin 1,73 3,5-5,5 g/dL • Another chemical tes

-

Globulin 2,50 2,5-3,5 g/dL Special Test

Ascites fluid analysis • Rivalta Negative Negative

Macroscopic • Colour• Clot • Clear

YellowNegative

Clear

• Another special test

- -

Microscopic• Erythrocyte count• Leucocyte count• PMN• MN

200/μL20/μL

0%100%

LABORATORY RESULTS| April 17th 2015

ELECTROCARDIOGRAM| April 17h 2015

• Sinus Rhtym, Heart rate 66 bpm • Frontal Axis : normal• Horizontal Axis : normal• PR interval : 0,136”• QRS complex : 0.085”• QT interval : 0.397”• Conclusion : sinus rhythm with HR 66 bpm,

low voltage

ELECTROCARDIOGRAM| April 17th 2015Interpretation

CHEST X RAYApril 17th 2015

• AP position, asymmetric, enough KV, less inspiration

• Soft tissue normal, Bone normal• Trachea is in the middle• Hemi diaphragm D and S were elevated• Phrenico costalis angle D and S covered by

radiopaque shadow• Pulmo D & S: BVP normal• Cor: site N, CTR 54%, cardiac waist (+) Conclusion : Pleural effusion lung D/S

CHEST X RAYApril 17th 2015

USG AbdominalApril 17th 2015

Conclusion : liver chirrosis, splenomegaly

CUE AND CLUE PL IDx PDx PTx PMo

Male/ 45 yo/ w26Anamnesis:Coffee ground vomitingBlacktarry stoolHistory of liver chirrosisPhysical examination:GCS 456BP: 120/70 mmHgPR: 84 bpmRR: 24 tpmTax: 36.8 degree celciusNGT clearShifting dullnes +Traube space dullness RT melena (+)Laboratory:Hb 7.2MCV 86.20MCH 26.9

1. Hematemesis Melena

1.1. Rupture variceal esophagus1.2. PUD

Endoscopy O2 6 lpm Nasal canulaInfusion NacL 0,9% 20 dpmNegative fluid balance 500 cc/dayGL/8 hours clear3x start fluid diet 6x200cc/dayInj ceftriaxone 1x1 g ivInj lansoprazole 1x30 mg ivBolus ocreotide 50 mcg iv continued drip ocreotide 50 mcg/hourLactulosa 3x30 cc per NGTTransfusion PRC 1 pack/day until Hb level > 8 g/dL

Monitoring:GCS, CBC, UOPS, VS EducationDisease, treatment, prognosis

CUE AND CLUE PL IDx PDx PTx PMo

Male/ 45 yo/ w26Anamnesis:Coffee ground vomitingBlacktarry stoolHistory of liver chirrosisSOBLeg swellingAbdominal enlargementPhysical examination:GCS 456NGT clearBP: 120/70 mmHgPR: 84 bpmRR: 24 tpmTax: 36.8 degree celciusNGT clearLung sound decreased basal area lung D/SPercussion lung basal D/S dullnessShifting dullnes +Traube space dullness Bilateral leg edemaMelena (+)Laboratory:Hb 7.2MCV 86.20MCH 26.90Leucocyte 2470Trombocyte 33000SAAG 1.53Albumine 1.73Globulin 2.50Analysa ascites (leucocyte MN 100%, rivalta -) Bil T/D/I : 0.8/0.56/0.24FH whitin normal limitCXR Pleural effusion lung D/SCXR sinus rhytm HR 66 bpm low voltage

2. Liver chirrosis CP B

2.1. Post necrotic hepatitis B infection

HBsAgAnti HCV

O2 6 lpm nasal canulaInfusion NacL 0,9% 20 dpmNegative fluid balance 500 cc/day

Monitoring:GCS, UOPS, VSAlbuminBil TDIFluid balance EducationDisease, treatment, prognosis

CUE AND CLUE PL IDx PDx PTx PMo

Male/ 45 yo/ w26Anamnesis:Coffee ground vomitingBlacktarry stoolHistory of liver chirrosisPhysical examination:GCS 456BP: 120/70 mmHgPR: 84 bpmRR: 24 tpmTax: 36.8 degree celciusNGT clearShifting dullnes +Traube space dullness RT melena (+)Laboratory:Hb 7.2MCV 86.20MCH 26.9

3. Anemia Normochrome Normocytair

3.1. dt acute blood loss3.2. dt chronic disease

Transfusion PRC 1 pack/day until Hb level > 8 g/dL

Monitoring:S, VS Hb level

EducationDisease, treatment, prognosis

CUE AND CLUE PL IDx PDx PTx PMo

Male/ 45 yo/ w26Anamnesis:Coffee ground vomitingBlacktarry stoolHistory of liver chirrosisPhysical examination:GCS 456NGT clearBP: 120/70 mmHgPR: 84 bpmRR: 24 tpmTax: 36.8 degree celciusNGT clearShifting dullnes +Traube space dullness RT melena (+)UOP 20cc/hourLaboratory:Ur 118.20Cr 2.21BUN/Cr : 24.99

4. Azotemia prerenal

4.1. volume depletion dt no1

Infusion NacL 0,9% 20 dpmTreat underlying disease

Monitoring:S, VS

EducationDisease, treatment, prognosis

CUE AND CLUE PL IDx PDx PTx PMo

Male/ 45 yo/ w26Anamnesis:Coffee ground vomitingBlacktarry stoolHistory of liver chirrosisSOBLeg swellingAbdominal enlargementPhysical examination:GCS 456BP: 120/70 mmHgPR: 84 bpmRR: 24 tpmTax: 36.8 degree celciusNGT clearLung sound decreased basal area lung D/SPercussion lung basal D/S dullnessBilateral leg edemaLaboratory:CXR Pleural effusion lung D/SCXR sinus rhytm HR 66 bpm low voltageAlbumine 1.73

5. Pleural effusion lung D/S

Analysa fluid pleura

Negative fluid balance 500 cc/day

Monitoring:S, VSUOPFluid balance EducationDisease, treatment, prognosis

THANK YOU