PATIENT IDENTITY Name (initial) : SSG Sex : Male Age : 46 years old Religion : Hindu Ethnic : Balinesse Marital Status : Married Address : Badung, Bali Occupation : Wiraswasta No. CM : 14046761 ToA : August 9 th (14.30) ANAMNESIS Chief Complaint: Enlargement of the abdomen Present History : The patient complained of enlargement of abdomen since 3 weeks BATH. The enlargement of his abdomen was complained to have happened slowly over time. Patient complained of cough since 1 month ago BATH. Initially, the cough was with no sputum and recently 1 week BATH there was presence of sputum in the cough. Complain of fever was denied by the patient There was shortness of breath complained 1 week BATH along with the enlargement of the abdomen.
Anamnesis Cont.....
Passing of urine was normal with a frequency of 4-5 times per day, with a volume of 150-200cc each time. There was no complain of vomiting blood. But there was a complain of black stools 2 days BATH. Past History Patien was treated in RS Bakthi Rahayu for 19 days. Patient was treated with Azithromycin and Furosemide Patient has a history of DM since 7 years ago.
Family History None of his family members have similar complaints. History of DM (-), HT (-), respiratory ds (-), GI ds (-), kidney ds (-)
Social History The patient does not smoke or drink alcohol Physical Examination Present status: General condition : moderately illness Level of Consciousness : E4V5M6 VAS : 2 BP : 120/70 mmHg Pulse rate : 88 bpm Resp. rate : 23 bpm Axillary temp. : 36,3 o C Weight : 52 kg Height : 159 cm BMI : 20,57 kg/m 2
PHYSICAL EXAMINATION General Status Eye : anemic -/-, icterus +/+, pupillary reflexes +/+ isocor, edema palpebrae -/- ENT : Tonsil T1/T1 Normal, Pharing: hiperemis (-), gland swelling (-) Neck : JVP PR +2 cm H 2 O, LN enlargement (-) Thorax : symmetrical Cor : Ins: ictus cordis unseen, Pal : ictus cordis unpalpable Per: UB : ICS 2 RB : right PSL LB : ICS 5 MCL sinistra Aus: S1S2 Single Regular, Murmur (-)
Lung: Ins : symetrical, spider naevi (-), ginekomastia (-) Pal: VF N/N, Per : sonor/sonor Aus : ves +/+, wh-/-, rh -/- PHYSICAL EXAMINATION Abdomen : Ins: Dist (+), ascites (+) Aus : Bowel sound (+) normal, Pal : Liver/spleen unpalpable, murphys sign (-), Per : Tympany(+), flank pain -/-, Extremeties : Warm +/+, Edema -/- +/+ -/-
LABORATORIES Complete Blood Count Parameter Result Unit Remarks Reference Range WBC 17,30 10 3 /L High 4,1 10,9 -Ne 15,40 89,00% 10 3 /L 2,5 7,5 -Ly 1,19 6,80% 10 3 /L 1,0 4,0 -Mo 0,68 3,90% 10 3 /L 0,1 1,2 -Eo 0,00 0,04% 10 3 /L 0,0 0,5 -Ba 0,00 0,16% 10 3 /L 0,0 0,1 RBC 3,18 10 6 /L Low 4,00 5,20 HGB 10,1 g/dL Low 12,00 16,00 HCT 29,7 % Low 36,0 46,0 MCV 93,4 fL Low 80,0 100,0 MCH 31,7 pg 26,0 34,0 MCHC 34,9 g/dL 31,0 36,0 RDW 15,90 % High 11,60 14,80 PLT 499,00 10 3 /L High 150 440 LABORATORIES Complete Blood Count Parameter Result Unit Remarks Reference Range MPV 9,3 fL 6,80 10,00 PT 15,60 second Normal = difference with control < 2 seconds INR 1,33 High 0,90 1,10 Control PT 13,50 APTT 29, 00 second Normal = difference with control < 7 seconds Control APTT 34,70 LABORATORIES Blood Chemistry Parameter Result Unit Remarks Reference Range SGOT 37,0 U/L High 11,00 - 27,00 SGPT 30,0 U/L 11,00 - 34,00 Total bilirubin 2,07 mg/dL High 0,30 1,10 Indirect bilirubin 0,43 mg/dL < 0,8 Direct bilirubin 1,639 mg/dL High 0,00 0,30 Protein total 7,23 g/dL 6,40 - 8,30 Albumin 2,248 g/dL Low 3,40 4,80 Globulin 4,982 g/dL High 3,20 3, 70 BUN 13,50 mg/dL 8,00 23,00 Creatinine 0,70 mg/dL 0,50 0,90 Random Blood Glukose 337,0 mg/dL High 70,00 140,00 LABORATORIES Blood Chemistry Parameter Result Unit Remarks Reference Range Alkali Phospatase 96,89 U/L 42,00 -98,00 Gamma GT 38,92 U/L High 7,00 32,00 LABORATORIES Blood Gas Analysis Parameter Result Unit Remarks Reference Range pH 7,47 High 7,35 7,45 pCO2 27,00 mmHg Low 35,00 45,00 pO2 91,00 mmHg 80,00 100,00 HCO3 - 19,70 mmol/L Low 22,00 26,00 TCO2 20,40 mmol/L Low 24,00 30,00 BEecf -4,00 mmol/L Low -2,00 2,00 SO2c 98,00 % 95,00 - 100,00 Na 127,00 mmol/L Low 136,00 145,00 K 5,70 mmol/L High 3,5 5,10 LABORATORIES Urinalysis Parameter Result Unit Remarks Reference Range pH 5,00 5 - 8 Leucocyte 500 leu/uL +3 neg Nitrite neg neg Protein 25,00 +1 neg Glucose 1.000 mg/dL +4 neg Ketone 5,00 mg/dL +1 neg Urobilinogen 4,00 mg/dL +2 neg Bilirubin 3,00 mg/dL +2 neg Erytrocyte 250,00 ery/uL +5 neg Colour brown pale yellow - yellow LABORATORIES Urinalysis Parameter Result Unit Remarks Reference Range Sedimen urine: - Leucocyte much /lp < 6/lp - Eritrocyte much /lp < 3/lp - Epitel - /lp - Cillinder granula cast + /lp - Crystal amorph + /lp - Bacteria + /lp THORAX AP - Cor : no enlargement detected - Pulmo : infiltrate in right parahiler dan percardial. - Right pleural sinus is sharp, left is unevaluated. - Right diaphragm is normal. - Bones: no abnormalities found
BOF -Increase in distribution of intestinal gas. -no radio opaque region along the urinary tract. -Contour of kidney left and right is unclear. -psoas line of left and right is unclear. -shadow of liver and spleen not seen enlargement. -there is osteophyte at VL 3,4,5 and the intervetebral space is good.
ASSESSMENT - Susp cirhosis hepatis - Mild anemia ec susp iron deficiency anemia + bleeding - DM tipe II