Morning Shift Report Saturday, 17-8-2013 dr.

dikara

Physician In Charge: 1A : dr. Dikara, dr. Satria, dr.Niva (Cardio) 1B : dr. Lya, dr. Fajar II : dr. Sigit III : dr. Shinta O Wardani, Sp.PD Summary of Data Base Male 47 yo/ w.26 Chief complain : black tarry vomiting and black tarry stool Patient suffered from black tarry stool and black tarry vomiting since 12 hours before admission, about 3-4 spoons, soft, likes petis and also black tarry vomiting 3-4 times, about 2-3 spoons accompanied with epigastric pain He also complained abdominal enlargement since 3 month ago weeks ago, he felt enlargment more biger gradually day by day He already been diagnosed liver cirrhosis since 3 month ago because hepatitis B infection and routinely control at gastrology out patient clinic, got 3 kinds drugs (spironolcton, propranolol and furosemide) History of hospitalized at RSSA about 5 times, with same complained and the last at july 2013 He is a seller, have been married, with 2 children He didnt complained about abdominal pain , fever and also shortnessS of breath History of hypertension: History of diabetes: History of family:-

Physical Examination Ward: BP = 130/80 mmHg PR = 88 bpm,regular , strong RR = 18 bpm

GCS 456 Icteric sclera (+)

Tax : 36,9C

General appearance looked moderate ill Head Neck Pale conjunctiva (+) NGT insertedclear JVP R + 3 cmH2O 30 degree

Chest

Heart: Lung:

Ictus invisible and palpable at ICS VI MCL Sinistra LHM ictus RHM: SLD , S1 S2 single, mur-mur (-) Symmetric, SF D=S, normal percussion, Rh - - Wh - -- - - Rounded, liver span 5-6 cm, traubes space tympani, undulation test (+) Sound of bowel (Normal) Leg edema -/- , warm acral, eritema palmaris (+)

Abdomen Extremities

Laboratory Finding (August 17th 2013 ) Lab Leucocyte Haemoglobine MCV MCH PCV Trombocyte SGOT SGPT Eo/Ba/Ne/Li/ Mo Value 6.930 9.0 100.40 33.80 26.70 35.000 140 60 2.3/0.1/67 .9/22.1/7. 2 16.4 12.6 1.41 Normal (Normal) 3.50010.000/L 11,0-16,5 g/dl 76-96 fl 26-34 35-50% 150.000390.000/L 11-41U/L 10-41U/L Lab Natrium Kalium Value 134 4.88 (Normal) 136-145 mmol/L 3,5-5,0 mmol/L

Chlorida RBS Ureum Creatinine APTT - Pasien - Kontrol

111 113 20.7 1.02

98-106 mmol/L < 200 mg/dl 10-50 mg/dL 0,7-1,5 mg/dL

42.6 25.4

Prolong

PPT Control INR

CUE AND CLUE Male/47 yo/w/26 A HM since 12 h ago Diagnosed liver cirrhosis since 3 moths ago Routine took omeprazole, spironolakton, and furosemide Abdominal enlargement since 3 month Nausea PE BP: 130/80 PR: 88 regular, strong RR: 18x/min Tax: 36.9 Undulation test (+) Liver span 5-6 cm Palmar eritem (+) NGT clear LAB: Hb:9.0 Leu: 6.93 Alb: 2.08 Thrombo: 35.000 OT:140 PT:60 Male/47 yo/w/26 A Diagnosed liver cirrhosis since 3 month ago Abdominal enlargement Nausea PE BP: 130/80 PR: 88 regular, strong RR: 18x/min

PL 1. Hemateesis melena

IDx 1.1 Ruptur VE 1.2 PUD 1.3 Gastritis erosiva

PDx Endoscop y

PTx Fasting GL/8h if 1x clear start liquid diet 6x200ccat ER 1x clear IVFD NaCl0.9%:D5% 1:115dpm Inj. Omeprazole 80mg continue with Drip 8mg/h until 3days or stop bleeding Inj. Metoclopramid 3x10mg (prn) Fluid balance -500/24h

PMo S, VS, urine prod, GL

2. Liver cirrhosis Child pugh C

2.1 post necrotic hepatitis B infection 2.2 post necrotic hepatitis c infection

endoscop y,USG Abdomen

Bed rest Fluid balance negative 500cc/h Fluid diet 6x200cc PO:Spironolakton, furosemide, propranolol postponed

S,VS, sign hepati c enche palopa thy

Tax: 36.9 Undulation test (+) Liver span 5-6 cm Palmar eritem (+) NGT clear Lab: HbsAg (+) Hb: 9.0 OT:140 PT:60 Alb: 2.08 Male/47 yo/w/26 Lab: Albumin: 2.08 3. Hypoalbumine mia 3. 1 dt liver chirrhosis 3.2 Hypercatabol ic stateS Protein esbach Treat underlying disease Alb level

Male/47 yo/w/26 LAB: PPT: 16.4 Cont:12.6 INR: 1.41 APTT: 42.6 Cont: 25.4 Male/47 yo/w/26 A: Epigastric pain Nausea Hematemesis melena PE: Abdomen rounded Udulation test (+) Epigastric tendenerss Lab: Hb: 9.0 Leu: 6.930 Male/47 yo/w/26 Lab: Hb:9.0 MCV: 100.40 MCH:33.80

4. Prolong FH

4.1 dt no 2

Transfusion FFP 10cc/kgbw

FH, TRALI

5. Epigastric pain+Hemamt emesis melena

4.1 Dyspepsia snyd dt no 2 4.2 SBP dt no 2

Acites analysis

Confirmed diagnosed Omeprazole as above

S, VS, PMN

6. Anemia MM

6.2 dt no 2 6.3 Def B12 6.4 Def Folic Acid

Treat underlying disease PO:Folic acid B6 3x1 B12 3x1

S, VS, PMN