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05-12-2014

Nama pasien Kamar Diagnosis


Ny Rejowati (IGD) 2.2 Essential HT + cephalgia
Ny Kumiatun (IGD) 11.2 Encephalopathy hepaticum +
acute viral hepatitis
Name : Mrs K
Age : 27 y.o
Sex : female
Adress : Jembel RT1RW5 Sugihwaras
Jenu Tuban
Date : December, 5th 2014
CHIEF COMPLAINT: decrease of consciousness
PRESENT ILLNESS HISTORY :
Patients had decrease of consciousness
suddenly since 2 days ago, before that she
complaint about pain on right upper quadrant
with black-bloody vomit 3 days ago, vomit
about 10 times a day (a quarter of glass every
vomit) without dregs, and Defecation (+) 5
times within 3 day with black-watery stool.
Miction (+)N. She also had fever since 1 week
ago, fluctuating. Headache (+). Shortness of
breath 3 days ago. Her eyes looks yellowish
since last night.
PAST ILLNESS HISTORY:
HT (-), DM (-), never consume
diabetic drugs
FAMILY ILLNESS HISTORY: the same
as the patient's complaints (-)
PERSONAL HISTORY, SOCIAL, and
ECONOMICS: Patients never drink
herbal medicine
VITAL SIGN :
GCS : 335
BP : 130/70 mmHg
PULSE RATE : 130 x / minutes
TEMP : 36,9oC
RR : 28 x / minutes
Head and Neck :
Anemic (-/-), Icteric (+/+), Cyanosis (-/-),
Dyspneu (-)
Pupil isokor 3 mm / 3 mm
Thorax : simetric bilaterally, retraction (-/-),
Pulmo : ves/ves, rh (-/-), wh (-/-)
Cor : S1-S2 single reguler, murmur(-), gallop(-)
Abdomen :
Abdomen : soepel, meteorismus
(-),BU(+N), hepar palpable 1 cm under
arcus costae (smooth surface, sharp
edge, compound),lien not palpable,
epigastrium tenderness (-),shifting
dullnes (-), undulasi (-), RUQ tenderness
(+), Ascites (-).
Extremity : warm, dry, red. Edem (-)
Female, 27 years old
Decrease of consciousness
haematemesis
melena
RUQ tenderness
Takipneu
Jaundice
Decrease of consciousness
Haematemesis melena
Jaundice
Encephalopathy hepaticum ec susp.
Cirrhosis hepatis
Haematemesis melena ec susp variceal
esophagus rupture
CBC
ECG
LFT
RFT
Abdominal USG
Thorax AP
Gastroscopy
HCV analyzed
Diffcount 0/0/77/20/3 Chloride 98
Hematokrit 38,1
Hemoglobin 13,6 Potassium 4,0
LED 25/52 Natrium 131
Leukosit 11.500
Trombosit 36.000
Bilirubin direct 3,08
SGOT 3649 Billirubin total 4,98
SGPT 1968 Alkali fosfatase 172
Ser creatinin 1,4
Urea 70 HBs-Ag (-)
GDA 136
Encephalopathy hepaticum ec cirrochis
hepatis DD susp .degenerasi maligna
Hematemesis melena ec variceal
esophagus rupture
Attach O2 nasal 2 lpm
Attach NGT
Attach DC
Inf assering loading 1000 cc Pz 1500 cc/24 h
Inj cefotaxime 3x2 gram
Inj metamizole 3x 1 g
Inj ranitidin 2x50 mg
Inj vit K 3x1 amp
Inj asam traneksamat 3x1 amp
PO : lactulose 4x CI
Vital signs
Complaint
Urinary production
Dubia ad bonam
Explaine to the family about the
disease of the family, about its
theraphy and intervention will be done,
and also about complication and
prognosis.