DR.

YASMITA-PPDS IPD

MORNING REPORT May 28th,2012

JAGA 1A : dr. Yasmita, dr. Daru , dr. Ungky (paru) JAGA 1B : dr. Ames , dr. Dyah JAGA 2 : dr. Didin Retno JAGA 3 : dr. Didi Candradikusuma, SpPD MODERATOR : dr. Niniek Budiarti, SpPD-KPTI

SUMMARY OF DATA BASE

Mr. Hadori/52 yo/W26 Chief complain: black tarry stool Px suffered from black-tarry stool since 1 day before admission, 7x, volume about -1 glass, followed by bloody vomitting, once at ER. Px suffered from decrease of conciousness since 22 hours before admission, gradually onset, look confuse. Px had been admitted before in RSUD Lawang for 2 days, because of epigastric pain, then referred to RSSA because of black-tarry stool.

Px also suffered from shortness of breath since 6 months ago, esp when walked > 5 meters. Px already complained about shortness of breath since 2 year ago, that made him couldnt worked again as a farmer. Px also complained about leg swelling since 6 months ago, and also abdominal enlargement. History of consumed traditional potion since 5 years ago, 2-3x/month.

PHYSICAL EXAMINATION
BP =100/60 mmHg PR = 120 bpm, reguler RR =28 tpm Tax : 37C
General appearance looked moderately ill Head Neck Thorax: Cor: Anemic + JVP R + 4 cmH2O 30 Invisible and palpable at ICS V MCL Sinistra RHM SL Dextra LHM ictus S1 S2 single Simetric, SF D = S, no additional breath sound GCS 334; looks normoweight Icteric + NGT: coffee ground

Lung:

Abdomen Extermities

Soufle, BS (+) Liver span 6cm, traubes space dullness, shifting dullness + Icteric-, edema at lower extremity

Lab Leukocyte

Value 13060

(Normal) 3,50010,000/L 11.0-16.5 g/dl 35-50% 150,000390,000/L 80-96 fl 26.5-33.5 pg

Lab Natrium Kalium Chlorida RBS

Value 141 4.97 119 107

(Normal) 136-145 mmol/L 3.5-5.0 mmol/L 98-106 mmol/L < 200 mg/dl

Haemoglobine 4.10 PCV Trombocyte 13 131.000

MCV MCH

86.10 27.20

Bil. T Bil. D Bil. I

5.11 5.09 0.02

< 1.10 mg/dl < 0.25 < 0.75

SGOT SGPT Albumin

18 10 2.2

11-41U/L 10-41U/L 3.5-5.5 g/dL

Ureum Creatinine PPT APTT

73.3 0.87 20.1 37.7

10-50 mg/dL 0.7-1.5 mg/dL K. 11.4 K. 27.2

URINALYSIS
Lab SG PH Leucocyte Nitrite Protein
1.020 5 1+ 3+

Value

Lab 10 x
Epithelia Cylinder Hyaline Granular Leukocyte Erythrocyte 40 x Erythrocyte

Value
+ -

Glucose
Erythrocyte Keton urine Urobilinogen Bilirubin

8-11
2-4 -

Leukocyte Crystal Bacteria

BGA
Temp PH PCO2 PO2 HCO3 O2 sat Art BE True o2 Conclusion : alkalosis respiratorik 37.4 C 7.52 20.5 123,9 16.7 99.2 -6.4 O2 7.35-7.45 35 45 mmHg 80 100 mmHg 21 28 m mol/L > 95 % (-3) - (+3) m mol/L

USG Abdomen (May 25, 2012)

USG Abd

Cirrhosis hepatis and sign of portal hypertension (ascites and spleenomegaly)

ECG

ECG

Sinus tachyaritmia, Heart rate 107-150 bpm Frontal Axis : LAD Horisontal Axis : Normal PR interval : 0,14 QRS complex : 0,09 QT interval : 0,28 Conclusion : sinus tachyaritmia, HR. 107-150 bpm

CUE AND CLUE

Male/52yo DOC since 22 hours before admission Black-tarry stool since 1 day ago Bloody vomitting PE: GCS 334 BP. 100/60 PR. 120 RR. 28 Liver span 5 cm Ascites + Edema lower extr + Lab: Leuko 13060 Hb 4.10 Albumin 2.2 Bilirubin T/D/I 5.11/5.09/1.02 PPT 20.1 sec (K.11.4) aPTT 37.7 sec (K.27.2)

PL
1. Decrease of conciousn ess

IDx
1.1 hepatic encepalopathy 1.2 septic condition

PDx
Number connectio n test

PTx
02 2-4 lpm nc Insert of NGT gastric lavage /8 hourclean 3xstart fluid diet 6x200 cc Insert catheter Inj. BCAA 2x500mg Inj. Ceftriaxone 2x1 gr inj,. Metronidazole 3x500mg

PMo
Subjecti ve BP HR RR GCS

CUE AND CLUE

Male/ 52 yo bloody vomitting black-tarry stool -PE: BP.100/60 mmHg PR.120 bpm RR.28 tpm Conjunctiva anemic NGT:bloody Liver span 5 cm Ascites + Extremity anemic RT: melena + Lab: Hb 4.10 albumin 2.2 PPT 20.1 sec (K.11.4) aPTT 37.7 sec (K.27.2)

PL
2. Upper GI bleeding

Idx
2.1 rupture VE 2.2 PUD

PDx
Endosc opy

PTx
- IVFD NaCl 0.9% 20 dpm -Insert NGT GL 3x (-) start fluid diet 6x200cc -Inj. Metochlopramid 3x10mg -Inj. Omeprazole 1x40mg IV - Somatostatin bolus 250mcgdrip 250mcg/hour

PMo
Subjec tive, FBS, 2HPP

CUE AND CLUE

Male/ 52 yo bloody vomitting black-tarry stool Decrease of conciousness -PE: BP.100/60 mmHg PR.120 bpm RR.28 tpm Conjunctiva anemic Sclera icteric NGT:bloody Liver span 5 cm Ascites + Traubes space dullness Extremity anemic RT: melena + Lab: Hb 4.10 albumin 2.2 Bilirubin T/D/I 5.11/5.09/1.02 PPT 20.1 sec (K.11.4) aPTT 37.7 sec (K.27.2)

PL
3. Cirrhosis Hepatis Child-Pugh C

Idx
2.1 post hep B infection 2.2 post hep C infection

PDx

PTx

PMo
Subjec tive, VS GCS

Ratio -Po: spironolacton 0-100mg alb/glob propanolol 2x20 mg , HbsAg, anti HCV

CUE AND CLUE

Male/52 yo Bloody vomitting Black-tarry stool Conjunctiva and extremity anemic Hb 4.10 MCV 86.10 MCH 27.20

PL

Idx

PDx

PTx
-transfussion WB 2 kalf/day

PMo
Subjectiv e comp, Hb level, hematem esis melena

4. 4.1 blood loss Anemia 4.2 chronic normoch disease rom normocy ter

Male/52 yo Albumin 2.2

5. hypoalb umine

5.1 dt cirrhosis hepatis 5.2 catabolic state

-Transfussion albumin 20%

Albumin level

Male/52 yo Ureum 73.3 Creatinin 0.87 BUN 39.3 UOP. 80cc/hour

6. Azotemi a prerenal

6.1 dt hematemesis melena

-IVFD NS 0.9% 20 dpm

Ureum and creatinin level, UOP

THANK YOU

Condition this morning

NGT coffee ground + GCS 345 BP. 110/90 PR. 130 RR. 26 UOP. 37.5 cc/hour