Morning Report

Liya Anjelina
1. Asril, male 54 YO. HCU 16
• Presenting complaint
Decrease of consciousness since 2 days ago
• History of presenting complaint
• Decrease of consciousness since 2 days ago, patient looks sleepy and difficult to communicate well with
family
• History of Abdomen pain since 2 month ago, increase since 1 weeks ago, pain felt like a stab at upper
right abdomen, pain does not radiate
• Decrease of appetite since 2 weeks ago
• Nause (+), vomite (-),
• Fever (-), cought (-), breathlessness (-)
• History of bloody vomited (-), black stool (-),
• History of sleep disorder (+),
• Micturation like tea (-
• Patient had been know as cirossis hepatis since 2 month ago
• Past medical history
• History of yellowish (-), History of diabetes (-), history of hypertension (-)

• Drug history
• none

• Family history
• History of liver disease (-)
• History of diabetes (-)

• Social history 
• History of drug abuse injection (-), history of alcoholic (-)
• general circumstances : severe
• level of consciousness : somnolen
• TD : 130/70 mmHg
• RR : 20 x/s
• N :98 x/s (regular)
• S : 36,5ºC
• VAS : difficult to evaluate
• Eye
• Conjunctiva anemic (+)
• Sclera icteric (-)

• Neck
• JVP 5-2 cmH20
• Spider navie (+)
• Lung:
• Inspection: simetric,
• Palpation: fokal fremitus simetris both of lung
• Percussion: sonor both of lung
• Auscultation: rales -/-, wheezing -/-
• Cor:
• Inspection: ictus wasn’t seen
• Palpation: ictus was palpated at 1 finger beside linea midclavicularis
• Percussion:
• Left border: 1 fingers medial LMCS sinistra
• Right border: linea sternalis dextra
• Upper border: RIC II
• Auscultation: regular rhythm

• Abdomen:
• Inspection: enlargement (-), collateral vein (-)
• Palpation: hepar palpable 2 finger BAC, 3 finger BPX, palpable blunt, hard consistency
• Percussion: tymphany, acites (-)
• Auscultation: bowel sound (+) N

• Extremities:
• Oedema -/-
• Irama sinus, HR : 98x/m gel P : 0.08, QRS :<0.12, segment ST elevasi (-), depresi (-), gel T inverted (-), axis :
normal
• Kesan : sinus rythm HR 98
 Hasil pemeriksaan yang telah dilakukan
Hb 11.9 g/dL Alb/glo 2.6 / 2.5

Ht 35 % OT/PT 84/69

Leukosit 26.580 /mm3 HbsAg Reaktif

Trombosit 168.000/mm3 Anti HCV Non reaktive

DC 0/4/88/2/6

PT 18.6 detik

APTT 32.1 detik

INR 1.78

Ureum 182 mg/dL

Kreratinin 1.3 mg/dL

Natrium 111 mmol/L

Kalium 3.1 mmol/L

Klorida 74 mmol/L
problem
• Encephalopaty
• hiponatremia
Diagnosis :

• Sirosis hepatis post necrotis stadium decompensated child pugh C with

encephalopathy hepaticum grade 2
• Hepatoma
• Hiponatremia ec low intake
Therapi
• Rest/ liquid diet hepatic 1 4 x 150 cc (1500 calories)
• NaCl 3% 12 hour perkolf
• Comafusin : triofusin = 1 : 1
• Madopar 3 x 360 mg
• Spironolacton 1 x 100 mg
• Propanolol 2 x 10 mg
• Lactulac 3 x 15 cc
Plan
• Fibroscan
• Cek AFP, bilirubin I/II, alkali fosfatase