dr.

Ferdi

MORNING REPORT
Date : Thrusday, May 09th 2019

Physician in charge
I : dr.Ferdi , dr. Hani ,dr. Angel, dr. Ajeng , dr. Emil (Kardio)
II Medcon : dr. Fredo
II CVCU : dr. Ramadi
II HCU : dr. Ikke
II UGD : dr. Efriko , dr. Rokhma
Chief on duty : dr. Ricky
Consultant on duty : dr. Syifa Mustika, SpPD-KGEH
Facilitator : dr. Laksmi Sasiarini, SpPD-KEMD
 Physical Examination
General appearance looked moderately ill Sat O2 97% on 4 lpm
GCS 456 VAS 5/10
BP 130/80 mmHg PR 104 bpm regular strong RR 22 tpm Tax oC
Head Conjuctiva Anemic (-), Sclera Icteric (+), Nystagmus (-), Meningeal Sign (-), Pupil Isocor
Neck JVP R+4 cmH20
Chest Symmetrical, retraction (-)
Lung Dullness | Sonor Decrease| Vesicular Rhonkhi : - | - Wheezing : -|-
Dullness | Sonor Decrease | Vesicular -
|- -|-
Dullness | Sonor Decrease| Vesicular -
|- - |-
Cardio Ictus invisible, palpable at MCL (S) ICS V
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) normal, shifting dullness (-)
Liver/ palpable at 4 fingers below arcus costae, liver was irregular (nodulated)
surface and blunt margin, liver span 14 cm, nodul epigastrium tenderness (-)
Lien/ Traube space tympany
Extremities Edema (+/+ minimal), pale (-), MMT 5 | 5 , Pathologic Reflex (-); Lateralization (-)
5|5
 Laboratory Findings (07/05/2019)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 6310 4.700 – 11.300 /µL Ureum 24.4 20-40 mg/dL

Hemoglobine 11 11,4 - 15,1 g/dl Creatinine 0.4 <1,2 mg/dL

PCV 34.9 38 - 42% Osm 285 275-295 mOsm/kg

Thrombocyte 222000 142.000 – 424.000 /µL Natrium 135 136-145 mmol/L

MCV 79.3 80-93 fl Kalium 3.17 3,5-5,0 mmol/L

MCH 25 27-31 pg Chlorida 107 98-106 mmol/L

Eo/Bas/Neu/ 0.8 / 0.5 / 84.3 0-4/0-1/51-67/ RBS 90 < 200 mg/dl

Limf/Mon /8.9 / 5.5 25-33/2-5
PPT 13 9.3-11.4 detik
SGOT 142 0-40 U/L APTT 28.5 24.8-34.4

SGPT 26 0-41 U/L INR 1.3 0.8-1.30

Albumin 2.55 3.5-5.5 g/dL HbsAg Reactive

Bilirubin total 6.47 <1.0 mg/dl AntiHCV NR
Bilirubin direct 5.92 <0.25 mg/dl

Bilirubin indirect 0.55 <0.75 mg/dl

 Urinalysis (08/05/2019)
LAB VALUE NORMAL LAB VALUE NORMAL
Turbidity Clear 10 x
Color Yellow Epithelia 0 ≤1
pH 6.5 4.5 – 8.0 Cylinder -
SG 1.016 1.005 – 1.030 Hyaline -
Glucose Negative negative Granular -
Protein Trace negative Other -
Keton 2+ negative
Bilirubin 3+ negative 40 x
Urobilinogen 16 negative Erythrocyte 2.5 ≤3
Nitrite Positive negative Leukocyte 1.5 ≤5
Leukocyte Negative negative Crystal -
Erythrocyte Trace-lysed negative Bacteria 4.4 ≤23 x 103/ml
Other
Electrocardiography (08/05/2019)
 Electrocardiography (08/05/2019)
Frontal Axis : normal
• Horizontal Axis : CCW rotation
• P wave : normal
• PR interval : 0.12”
• QRS complex : 0.08”
• Q wave : No pathologic signs
• QT interval : 0.43”
• QT interval corrected : Isoelectric
• ST segment : isoelectric
• Others :

Conclusion : Sinus tachycardia HR 120 bpm

Chest X-Ray (26/04/2019)
 Chest X-Ray (26/04/2019)
• AP position, symmetric, enough KV, less inspiration
• Soft tissue was thin and bone was normal
• Trachea in the middle
• Hemidiaphragm D was hard to be evaluated and S was dome-
shaped
• Phrenico-costalis angle D was hard to be evaluated because of
opacity and S was sharp
• Pulmo: bronchovesicular pattern was normal, no visible of
infiltrate / nodule
• Cor: site N, size CTR 50%, shape N, elongation aorta (-), cardiac
waist (+), shift to right side.

Conclusion:
1. Aortic knob prominent
2. Pleural effusion Right
BOF (24/04/2019)
 BOF (24/04/2019)
Increase visible gas distribution until to pelvic cavity, mixed with
fecal material.
Visible coiled spring sign which formed sentinel loop. No visible
of step ladder sign.
No visible of free air at subdiafragma.
Shadow of liver and lien was not increase in size. Renal contour
bilateral were unclear.
No invisible of radiopaque across urinary tract.
Shadow psoas bilateral were unclear
Conclusion: Suggestive of functional ileus, no visible of
pneumoperitoneum
Abdominal USG (03/04/2019)
Abdominal USG (03/04/2019)
 Abdominal USG (03/04/2019)
 Hepar : size was increase with craniocaudal size ±16 cm; irregular
surface; blunt margin, echoparenchym was rough heterogen; VH/VP was 16 cm/s;
Visible solid mass isohyperechoic with the size of ± 13.5 cm x 9.5 cm x 8.9 cm
 Gall bladder : size and shape were normal; no visible stone/mass/sludge; wall
thickening (-)
 Pancreas : size was normal; homogenous parenchym; calcification (-)
 Lien : size was normal; mass (-); cyst (-)
 Renal D/S : size was normal; echo cortex normal; margin of sinus cortex was
definite; ectasis at pelvicocalyceal (-); no visible stone/mass/cyst
 Vesica urinaria : enough content; smooth wall, mass (-), calcification (-)
 Prostat : size was normal, mass (-), calcification (-)
 No visible mass/lymph nodes nodules, Visible pleural fluid right.
Conclusion: Hepatomegaly with moderate liver fibrosis (Nishiura score 5), with
hepatoma. No sign of portal hypertension. Right pleural effusion.
Colon in loop (07/05/2019)
 Colon in loop (07/05/2019)
• Kontras barium yang diencerkan dimasukkan ke dalam anus melalui foley
catheter
• Tampak kontras mengisi rectum, sigmoid, colon descenden, fleksura
lienalis, colon transversum, fleksura hepatica, colon ascenden dan masuk
ke ileocaecal junction dengan lancer.
• Mucosa dan haustra tampak regular
• Tidak tampak penyempitan/pelebaran abnormal, filling defect maupun
additional shadow
• Kesimpulan: colon in loop tidak tampak kelainan, Ground-glass
appearance di cavum abdomen atas yang mendesak gas usus ke caudal
dapat merupakan massa di hepar.
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
1. Hepatoma Non pharmacology S
Mr. M / 53 y.o / Ward IW
due to - Soft diet with 1900 kkal VS
Subjective Hepatitis B per day, Fiber 25 – 45 VAS
Upper right abdominal pain
infection g/day, protein 1.2 – 1.5
Bloating sensation g/kgBW/day Education:
Got diagnosed with Tell the
Hepatoma since 3 years ago
Pharmacology patient to
Objective • PO Telbivudine 1 x 600 take
mg medicine
Icteric +
Abdomen palpable at 4 • PO Spironolactone regularly
fingers below arcus costae, 1x100 mg
liver was irregular • PO Lactulose 3xCI
(nodulated) surface and • PO Propranolol 2 x 20
blunt margin, liver span 14 mg
cm
Laboratory
HbsAg Reactive
USG: Hepatomegaly with
moderate liver fibrosis
(Nishiura score 5), with
hepatoma.
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
2. Moderate - PO Paracetamol 3 x 500 VAS
Mr. M / 53 y.o / Ward IW
cancer pain mg
Subjective PO Codein 3 x 10 mg Education:
Got diagnosed with -
Tell the
hepatoma possible
Objective cause of
VAS 5/10
pain
Laboratory
USG: Hepatomegaly with
moderate liver fibrosis
(Nishiura score 5), with
hepatoma.
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
3. Mild 3.1 GI Loss - Soft diet with 1900 kkal Appetite of
Mr. M / 53 y.o / Ward IW
hypokalemia 3.2 Renal Loss per day, Fiber 25 – 45 patient
Subjective g/day, protein 1.2 – 1.5 Electrolyte
Nausea and vomiting when
g/kgBW/day with High serum
eating potassium
Bloating sensation  Education:
patient can’t eat Eat high
potassium
Objective diet
-
Laboratory
K : 3.17 mmol/L
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
4. Nausea and 4.1 dt - IV Metoclopramide 3 x Signs of
Mr. M / 53 y.o / Ward IW
vomiting Mechanical 10 mg dehydration
Subjective 4.2 PUD
Nausea and vomiting +
Education:
Objective Adequate
Abdomen palpable at 4 oral intake
fingers below arcus costae,
liver was irregular
(nodulated) surface and
blunt margin, liver span 14
cm

Laboratory
-
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
5. 5.1 Decrease - Soft diet with 1900 kkal Albumin
Mr. M / 53 y.o / Ward IW
Hypoalbumine of synthesis per day protein 1.2 – serum
Subjective mia 5.2 Low intake 1.5 g/kgBW/day
Got diagnosed with
Education:
hepatoma Eat high
Objective protein diet
Edema lower extremity
bilateral +

Laboratory
Albumin: 2.55 g/dL
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
6. Right pleural 6.1 Metastatic - Protein diet 1.2 – 1.5 Albumine
Mr. M / 53 y.o / Ward IW
effusion process (?) g/kgBW/day CXR after
Subjective 6.2 Treat underlying pleural fluid
Shortness of breath since 2 -
Hypoalbumine disease evacuation
weeks mia Plan to evacuate Respiratory
Objective -
R/R 22 tpm pleural fluid rate
Dullness and decrease lung Education:
sound at right side of lung
Tell the
possible
Laboratory cause of
Albumin : 2.55 g/dL
pleural
effusion
 Problem Analysis

Chronic Cirrhosis
Hepatitis B
Infection
History of
Hepatoma Smoking
on
s ati
g sen Decrease of protein
tin synthesis
Blo a Metastasis

Nausea and Hypoalbuminemia

Vomiting Pleural effusion

Hypokalemia
 Risk Factor Analysis
Problem Risk Factor Fact
Hepatoma Gender (men) Gender (men)
Race Asian Pacific
Alcoholism Chronic viral hepatitis
Chronic viral hepatitis Cirrhosis
Aflatoxin
Asian Pacific
Cirrhosis
Obesity
Type 2 diabetes mellitus
Inherited metabolic disorders
Vinyl chloride, thorium dioxide
Anabolic steroid
Schistosomiasis
Tobacco
Non alcoholic fatty liver disease
 Management Analysis

HEPATOMA 1. Resection liver We perform paliatif terapy for this patient

2. Transplantasi Liver because the other terapy are difficut to
3. Percutaneous tumor ablation perform
4. Palliative therapy
Key message Diagnosis
Pathophysiology Key Messages
 Key message social

• Explain to the patient/family about condition of the

patient
• Cognitive behavioral therapy including family
intervention and support may be needed by the
patient
• Educate family and the patient about palliative
therapy and how to managing quality of life
 Condition This Morning

• GCS : 456
• BP : 120/70 mmHg
• HR : 98 bpm
• RR : 20 tpm
• Tax : 36,9oC