Morning Shift Report

Saturday, 17-8-2013
dr.dikara

Physician In Charge:
1A
: dr. Dikara, dr. Satria, dr.Niva (Cardio)
1B
: dr. Lya, dr. Fajar
II
: dr. Sigit
III
: dr. Shinta O Wardani, Sp.PD
Summary of Data Base
Male 47 yo/ w.26
Chief complain
: black tarry vomiting and black tarry stool
Patient suffered from black tarry stool and black tarry vomiting since 12
hours before admission, about 3-4 spoons, soft, likes petis and also
black tarry vomiting 3-4 times, about 2-3 spoons accompanied with
epigastric pain
He also complained abdominal enlargement since 3 month ago weeks
ago, he felt enlargment more biger gradually day by day
He already been diagnosed liver cirrhosis since 3 month ago because
hepatitis B infection and routinely control at gastrology out patient clinic,
got 3 kinds drugs (spironolcton, propranolol and furosemide)
History of hospitalized at RSSA about 5 times, with same complained and
the last at july 2013
He is a seller, have been married, with 2 children
He didnt complained about abdominal pain , fever and also shortnessS of
breath
History of hypertension: History of diabetes: History of family:Physical Examination
Ward: BP =
130/80 mmHg

PR = 88 bpm,regular ,
strong

RR = 18
bpm

Tax :
36,9C

General appearance looked moderate ill

GCS 456

Head

Icteric sclera (+)

Pale conjunctiva (+)

NGT insertedclear

Neck

JVP R + 3 cmH2O 30 degree

Chest
Heart:

Ictus invisible and palpable at ICS VI MCL Sinistra

LHM ictus RHM: SLD , S1 S2 single, mur-mur (-)
Symmetric, SF D=S, normal percussion,
Rh - Wh - -- - - -

Lung:

Abdomen

Rounded, liver span 5-6 cm, traubes space tympani,

undulation test (+) Sound of bowel (Normal)

Extremities

Leg edema -/- , warm acral, eritema palmaris (+)

Laboratory Finding (August 17th 2013 )

Lab

Value
(Normal)

Lab

Value
(Normal)

Leucocyte

6.930

3.50010.000/
L

Natrium

134

136-145
mmol/L

Haemoglobi
ne
MCV
MCH

9.0
100.40
33.80

11,0-16,5
g/dl
76-96 f
26-34

Kalium

4.88

3,5-5,0
mmol/L

PCV

26.70

35-50%

Chlorida

111

98-106
mmol/L

Trombocyte

35.000

150.000390.000/
L

RBS

113

< 200 mg/dl

SGOT

140

11-41U/L

Ureum

20.7

10-50 mg/dL

SGPT

60

10-41U/L

Creatinine

1.02

0,7-1,5 mg/dL

Eo/Ba/Ne/Li/
Mo

2.3/0.1/
67.9/22.
1/7.2

APTT
Pasien
Kontrol

42.6
25.4

Prolong

PPT
Control
INR

16.4
12.6
1.41

Normal

CUE AND CLUE

PL

IDx

PDx

Male/47
yo/w/26
A
HM since 12 h
ago
Diagnosed liver
cirrhosis since
3 moths ago
Routine took
omeprazole,
spironolakton,
and furosemide
Abdominal
enlargement
since 3 month
Nausea

1.
Hemateesi
s melena

1.1 Ruptur
VE
1.2 PUD
1.3
Gastritis
erosiva

Endosc
opy

PE
BP: 130/80
PR: 88 regular,
strong
RR: 18x/min
Tax: 36.9
Undulation test
(+)
Liver span 5-6
cm
Palmar eritem
(+)
NGT clear
LAB:
Hb:9.0
Leu: 6.93
Alb: 2.08
Thrombo:
35.000
OT:140
PT:60

PTx
Fasting GL/8h if 1x
clear start liquid diet
6x200ccat ER 1x
clear
IVFD NaCl0.9%:D5%
1:115dpm
Inj. Omeprazole
80mg continue
with
Drip 8mg/h until
3days or stop
bleeding
Inj. Metoclopramid
3x10mg (prn)
Fluid balance
-500/24h

PMo
S,
VS,
urine
prod,
GL

Male/47
yo/w/26
A
Diagnosed liver
cirrhosis since
3 month ago
Abdominal
enlargement
Nausea

2. Liver
cirrhosis
Child pugh
C

2.1 post
necrotic
hepatitis B
infection
2.2 post
necrotic
hepatitis c
infection

endosc
opy,US
G
Abdom
en

Bed rest
Fluid balance
negative 500cc/h
Fluid diet 6x200cc
PO:Spironolakton,
furosemide,
propranolol
postponed

S,VS,
sign
hepa
tic
ench
epal
opat
hy

Male/47
yo/w/26
Lab:
Albumin: 2.08

3.
Hypoalbum
inemia

3. 1 dt
liver
chirrhosis
3.2
Hypercata
bolic
stateS

Protein
esbach

Treat underlying
disease

Alb
level

Male/47
yo/w/26
LAB:
PPT: 16.4
Cont:12.6
INR: 1.41
APTT: 42.6
Cont: 25.4

4. Prolong
FH

4.1 dt no
2

Transfusion FFP
10cc/kgbw

FH,
TRAL
I

Male/47
yo/w/26
A:
Epigastric pain
Nausea

5.
Epigastric
pain+Hem
amtemesis
melena

4.1
Dyspepsia
snyd dt no
2
4.2 SBP dt

Confirmed diagnosed
Omeprazole as above

S,
VS,
PMN

PE
BP: 130/80
PR: 88 regular,
strong
RR: 18x/min
Tax: 36.9
Undulation test
(+)
Liver span 5-6
cm
Palmar eritem
(+)
NGT clear
Lab:
HbsAg (+)
Hb: 9.0
OT:140
PT:60
Alb: 2.08

Acites
analysi
s

Hematemesis
melena
PE:
Abdomen
rounded
Udulation test
(+)
Epigastric
tendenerss
Lab:
Hb: 9.0
Leu: 6.930
Male/47
yo/w/26
Lab:
Hb:9.0
MCV: 100.40
MCH:33.80

no 2

6. Anemia
MM

6.2 dt no
2
6.3 Def
B12
6.4 Def
Folic Acid

Treat underlying
disease
PO:Folic acid
B6 3x1
B12 3x1

S,
VS,
PMN