dr.

Dheni
Duty Report
Saturday, March 24th 2020

Physician in charge:
IA : dr Dheni, dr Mazen, dr Aditya
II : dr
Consult : dr ferdi
HCU : dr Caesar
UGD : dr Ajeng, dr Amanda, dr Ade
Chief On Duty : dr Ricky C
Consultant : dr. M Anshory Sp.PD

Summary of Database:
Mrs M/59 y.o/ward 24C bed 1.2

Chief complaint: Abdominal Mass

Anamnese
Patient felt there was mass at her abdomen, upper site of abdomen. Mass became bigger and bigger,
at begin the mass only felt in low back site at the right side. Then the mass grew bigger till the upper right
side and center side in 1 years before admission. There wasn’t felt pain at begin, but 4 month before
admission, patient felt pain when provoked with movement and pressure at the mass. Pain only felt in mass
area only, other area was in normal condition (without pain)
Patient felt her appetite decreased 4 month before admission. Patient felt nausea and vomiting 4
month before admission, with frequency was escalated. Patient felt her body weight was decreased, about 10
kilograms in 4 months.
Lump in area submandibular felt in 6 month before admission, it was about 4-5 lumps in
submandibular area. It was small at beginning and became bigger. Patient never had chronic cough before.
There wasn’t contact with tuberculosis patient and never got tuberculosis medication before.
Patient got medication in urology department before with adrenal tumor in march 2019. USG
resulted in march 2019 was enlargement adrenal gland. Patient routine control in urology department till
February 2020 and got USG abdomen examination. USG abdomen result was tumor size became bigger than
before.
Patient had hypertension and diabetes mellitus history for 4 months before admission. With
amlodipine 10 mg and metformin 500 mg, got from public health service before. Patient only drink the
medicine only when she felt not in good condition.

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Physical Examination
General appearance = looked moderately ill GCS 456, VAS 2/10 with provocation
BP = 126/80 mmHg PR = 80 bpm RR = 18 tpm Tax : 36,4°C

Head Conjungtiva anemic (-) Icteric sclera (-)

Neck JVP R+2 cmH2O, lymphnode enlargement (+) multiple, with diameter 0,5 –
1 cm, mobile, pain (-) in submandibular dextra region
Chest
Heart: Ictus palpable at ICS V MCL S
LHM ≈ ictus // RHM: SL D
S1, S2 single, murmur (-) gallop (-)
Lung: Symmetric, SF D=S,
Percusion: S S V V Rh - - Wh - -
S S V V - - - -
S S V V - - - -
Abdomen Soefl, bowel sound (+) normal
liver span 8 cm, traube space thympani
Mass palpable from upper right side posterior and anterior till epigastrium
region. Fixed, pain (+) with provocation, with diameter  10 cm
Extremities Warm akral, CRT<2, edema (-)

Laboratory Findings (04/02/2019)

Lab Value (Normal) Lab Value (Normal)

Haemoglobine 13.6 11,4 -15,1 g/dl Ur 53 16.6 – 48.5

Leukocyte 14.480 4.700 – 11.300/µL Cr 1,10 <1.2

Hematocrit 40,5 38 - 42%

Trombocyte 491.000 142.000– 424.000 NA 135 136-145 mmol/L

/µL

MCV 84,10 80-93 fl K 3,65 3,5-5,0 mmol/L

MCH 27,90 27-31 pg Cl 106 98-106 mmol/L

Eo/Bas/Neu/limf/ (-) 0-4/0-1/51-67/25-

Mon 33/2-5

SGOT (-) 0-40 LDH (-)

SGPT (-) 0-41 CD4 (-)

Alb (-) 3,5-5,5 g/dl Asam Laktat (-) 0,5 – 2,2 mmol/L

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Laboratory Findings (12/02/2020)

Lab Value (Normal)

HbA1C 8,36%

GD1 131

GD2 137

Cortisol Pagi 410,20

CXR (20/09/2019)
- Cardiomegaly

USG Abdomen (11/03/2019)

Enlargement Adrenal Gland Dextra

USG Abdomen (02/03/2020)

Suspect myolipoma soft tissue abdomen/retroperitoneal, uk 11,76 cm x 11,68 cm x 10,88 cm

USG Tyroid (11/02/2020)

1. Sponiform multiple at right tyroid gland (TIRADS 1)
2. Multiple Lymphadenopaty submandibular dextra (Benign characteristic)

FNAB Tyroid Dextra (18/03/2020)

Hanya didapat jaringan ikat dan lemak at site pricise with USG result

MSCT Abdomen (09/03/2020)

Solid mass heterogen with size 10cm x 11,9 cm x 13,6 cm that connected with right lobe of liver
and destructed upper pole right kidney. It spread to the musculus quadratus lumborum dextra and
musculus oblique interna dextra, Malignance characteristic. Please cross check with Patology
Anatomy Examination

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 CUE AND CLUE PL IDx PDx PTx PMo and
PEdu
Mrs M/59 y.o/ward 24C bed 1.2 1. Upper region 1.1 Adrenal Morning Non Pharmacology: Subjective,
Subjective abdominal mass Gland Cortisol Soft Diet 1800kcal/days vital sign,
- Abdominal mass since 1 years ago. + Decrease BW Tumor VAS
- Abdominal mass growth became more + Pain 1.2 Soft Tissue
Pharmacology:
bigger Carcinoma
Chemoterapy session
- Mass felt in posterion abdomen and then
(waiting properly examined
grew to the right anterior upper kuadran an PEdu:
and discussion) Mass
epigastrium area
- Pain felt 4 month before admission sometimes
- Nausea and vomit felt 4 month before made
admission abdoninal
discomfort,
- Decrease of Body Weight, 10 kilograms in 4
pai, nausea
month
and vommit
Objective
Mass palpable from upper right side posterior
and anterior till epigastrium region. Fixed, pain
(+) with provocation, with diameter  10 cm

USG Abdomen
USG Abdomen (11/03/2019)
Enlargement Adrenal Gland Dextra

USG Abdomen (02/03/2020)

Suspect myolipoma soft tissue
abdomen/retroperitoneal, uk 11,76 cm x 11,68
cm x 10,88 cm

MSCT Abdomen
Solid mass heterogen with size 10cm x 11,9 cm
x 13,6 cm that connected with right lobe of liver
and destructed upper pole right kidney. It spread
to the musculus quadratus lumborum dextra and
musculus oblique interna dextra, Malignance
4
characteristic. Please cross check with Patology
Anatomy Examination
Mrs M/59 y.o/ward 24C bed 1.2 2. Multiple  BTA sputum Non Pharmacology: Subjective,
Subjective Lymphadenopat  Rapid Test (-) cough, BTA
Multiple lump in neck since 6 months before y submandibular Moleculer evaluation
admission dextra ( Tes cepat Pharmacology:
molekuler - PEdu:
- OAT, waiting result
Objective TCM Drug
BTA and TCM compliance,
lymphnode enlargement (+) multiple, with
diameter 0,5 – 1 cm, mobile, pain (-) in
submandibular dextra region

USG Tyroid
USG Tyroid (11/02/2020)
1. Sponiform multiple at right tyroid gland
(TIRADS 1)
2. Multiple Lymphadenopaty
submandibular dextra (Benign
characteristic)

FNAB Tyroid Dextra (18/03/2020)

Hanya didapat jaringan ikat dan lemak at site
precise with USG result

Mrs M/59 y.o/ward 24C bed 1.2 3. DM type 2 - Fasting Glucose Non Pharmacology: Subjective,
Subjective and 2 hours - Diet control VS,
Patient got metformin 500 mg, got from public after meal
health service before. Patient only drink the Glucose test PEdu:
medicine only when she felt not in good Patient’s
Pharmacology: condition,
condition.
- PO Metformin 3x 500 drug
Objective mg compliance,
Lab (12/02/2020)
HbA1C 8,36
GD1 131
GD2 137

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Mrs M/59 y.o/ward 24C bed 1.2 4. Nausea and (-) (-) Non Pharmacology: Subjective,
Subjective Vommit due to - Soft Diet VS, intake
- Patient felt her appetite decreased 4 month no 1
before admission. PEdu:
Pharmacology:
- Patient felt nausea and vomiting 4 month Mass
- IVFD NaCl 0,9% sometimes
before admission, with frequency was
escalated 1500cc/days made
Objective: - IV Metoclopramide abdoninal
- BP : 126/80 mmHg 3x10mg discomfort,
- HR : 80x/m pai, nausea
- T : 36.8C and vommit
- RR 18x/m, reguler