Morning Report

23/10/2019

DM Adel and DM Atika

 IDENTITY

• Name: Mr. FH
• Age: 24 years old
• Gender: Male
• Address: Naibonat
 ANAMNESIS
Main Complaints: right upper abdominal pain
Current Disease History:
Referral patients from Naibonat Hospital with RUQ pain ec susp. Liver
abscess (size 7,25 cm) and liver mass. The patient complains of right
upper abdominal pain for one week. Fever intermitten. Continuous pain.
Reduced when given pain killer medication. The patient can only fall
asleep because of pain. Nausea (-), vomiting (-), eating well drinking,
defecating and urinnate normally.
Past Medical History : typhoid fever (+)
Past Medical Medicine:
• IVFD NS 0,9% 20 tpm
• Inj. Ceftriaxone 2x1 gr / iv
• Omeprazole 2x40 mg /iv
• Metronidazole 3x500 mg /iv
• Antrain 3x1 gr /iv
GCS : E4V5M6
VITAL SIGN
BP : 110/70 mmHg
HR : 76x/min
RR : 17x/min
Temp: 36,7 C
SpO2: 99%
 Physical Examination
• Head: normocephal (+)
• Eyes: Conj. Anemic - / -, jaundice sclera - / -, isochoric pupils, RCl ++ / +, RCTL ++ /
+, hematoma in the palpebra sinistra.
• Ear : Otore (-/-)
• Nose : Rhinore (-/-)
• Neck : palpable lymph node (-)
• Thoraks:
– Inspection: symetrical chest expousior
– Palpation: tenderness (+)
– Percussion: sonor in both lung fields
– Auscultation:
Pulmo: ves +/+, rh - / -, wh - / -
Cor: S1, S2 regular, gallop (-), Mur (-)
 Physical Examination
• Abdomen :
– Inspection: convex
– Auscultation: bowel sound (+) normaly
– Palpation: palpable enlargement of the four fingers under the arcus costa
– Percussion: deaf in the upper right region

• Extremities: warm acral (+/+), CRT <2 seconds.

 Check up result Laboratorium
Hb 11,8 (L) g/dl 12.0-16.0

Hematokrit 39,7 (L) % 37.0- 47.0

MCV 102.2 (H) fL 81.0- 96.0

MCH 30.4 pg 27.0- 36.0

Leukosit 7,17 ribu/ul 4.0-10.0

Trombosit 261 ribu/ul 150-400

PT 9,5 (L) Detik 10,8-14,4
INR 0,95
APTT 29,0 Detik 26,4 – 37,6
GDS 112 Mg/dl 70-150
BUN 7,0 Mg/dl <48
Creatinine 0,41(L) Mg/dl 0,6 -1,1
Natrium 137 Mmol/L 132-147
Kalium 4,0 Mmol/L 3,5-4,5
Klorida 102 Mmol/L 96-111
Calcium Ion 1,290 Mmol/L 1,120 – 1,320
Total Calcium 2,6 (H) Mmol/L 2,2 – 2,55
Bilirubin direct
Bilirubin indirect
Bilirubin total
 USG
Liver : enlarged size, hypoechoic lesions appear,
round shape, relatively firm border, 7.25 cm in
diameter in the right lobe of the liver with
minimal color doppler vascularity at the edge of
the lesion.
Conclusion : suspect right hepatic lobe abscess
mass
 Assessment
• Abdominal pain ec suspect abses hepar dd
liver mass
 Planning therapy
• IVFD NS 0,9% 20 tpm
• Inj. Ceftriaxone 2x1 gr / iv
• Inj. Ketorolac 3x30mg / iv
• Inj. Metronidazole 3x500mg / iv