KASUS 1

I.

IDENTITAS PASIEN
NamaPasien : Tn. M
Bangsal
: A1 ruang 6/1
Umur
: 51 tahun
Tanggal MRS: 6 Juli 2014
Tanggal KRS : belum
Diagnosa
: Anemia + Cirosis Hepatic + Ascites permagna + CKD

II. SUBYEKTIF (Saat MRS)

2.1. Keluhan Utama
Badan lemas, perut besar, dan kaki bengkak.
2.2. Riwayat Penyakit Terdahulu
Tahun 2001 : hepatitis B
Tahun 2010 : Liver kronis
Februari 2014 : encepalopati stage III + ascites permagna +
kardiohepatorenal syndrome.
2.3. Riwayat Pengobatan
lamivudin
Curcuma
Laxadine 4x1C
2.4. Riwayat Penyakit Keluarga
(-)
2.5. Alergi obat
(-)

Kanamicin 3 x 2
Omeprazol 2x1

III. OBYEKTIF dan MONITORING

Parameter
Tekanan
Darah
Suhu
Nadi
RR
GCS
Lemas
Kaki bengkak
mual
Perut
membesar
HB

5/7
120/8

6/7
90/6

7/7
100/6

8/7
100/6

9/7
120/7

10/7
90/7

0
36
80
20
456

0
36
80
20
456

0
36
80
20
456

0
36
88
22
456

0
37,5
82
20
456

0
37
80
20
456

6,0

6,8

WBC

6.000

3800

GDA
BUN
SrCr
Na
K
Cl
BPJ
RBC
HCT
MCV
MCH
MCHC
albumin

188
44
3,2
130,9
3,78
95
520
1.74
16,8
96,8
34,5
35,6

7,7
410
0

2.13
21.1

2,42
24.1

1.9

IV. Assessment
4.1 Terapi Pasien
Obat
Aminofusin hepar
Spironolacton
Lasix
Asam folat
Vitamin B complex
Transfuse PRC
Ketosteril
Salofalk
HP pro
Vip albumin
Propranolol
Albumin

Dosis

Rute

1x1
1x25 mg
1-0-0
1x1
2x1
2 kantong
3x1
2x1
3x1
3x2
1x40mg
1x1

Infuse
Iv
Iv
Po
Po
Iv
Po
Po
po
Po
Po
iv

5/7

6/7

Tanggal
7/7
8/7

9/7

10/7

KASUS 2
Mrs GE, an 86-year-old Caucasian woman, was taken to A&E from her care home.
She had a 1-week history of tiredness, weakness, and some epigastric discomfort
and nausea. She had had one episode of malaena the previous day and coffee
ground vomit earlier today. Her past medical history included osteoarthritis, gout,
hypertension, and resting tremor secondary to anxiety. She had no known drug
allergies and was taking the following prescription drugs:
-

Propranolol 40 mg up to three times daily when required

Indometacin 25 mg three times daily
Arthrotec (diclofenac 50 mg + misoprostol 200 micrograms) tablets twice

daily
Allopurinol 100 mg daily
Ramipril 10 mg daily
Simvastatin 40 mg at night

Her haematology and biochemistry results on admission were:

-

Haemoglobin 8.3 g/dL (reference range 1113)

Haematocrit 0.31 (0.360.46)
C-reactive protein 45 mg/L (04)
Packed cell volume (PCV) 0.275(0.3600.470)
International normalised ratio (INR) 1.01
Mean cell volume (MCV) 75 fL (80100)
Sodium 141 mmol/L (135145)
Potassium 4.0 mmol/L (3.55)
Mean cell haemoglobin (MCH) 25 pg (2732)
Creatinine 105 micromol/L (4584)
Platelets 264 109/L (150400)
Urea 20.3 mmol/L (1.78.3)
Her Helicobacter pylori test was reported as positive.

Her blood pressure was recorded as 115/59mmHg, her respiratory rate was 24 and
her pulse rate 155 beats per minute (bpm). A provisional dia-gnosis of upper
gastrointestinal (GI) bleeding was made and she was admitted to the ward.