Case Report Ward

Wednesday, 25/01/2017

Ward Physician :
Dr. Rizka
Abby W
Widya Kesuma

Patients Recapitulation
1. Ny T/54 years old/ Acute Diarrhea ,
electrolite imbalance, abdominal
mass
2. Mr. S/48 years old/ Multiple Myleoma
3. Ny TM/80 years old/ Susp Pnemonia,
electrolite imbalance

Identity
Name : Mrs, T
Age : 54 YO
Education
: High School
Marriage status : Married
Religion : Islam
Occupation : House Wife
Date Enters : January 25 th 2017

Anamesis
Main complaint :
Watery Stool since 3 day BHA

Anamnesis
Present illness :
Pasien came with chief complaint of watery stool more
than 5 times since 3 days BHA. The Stool colour are
brown, watery, with slime but there is no blood.
Complaints accompanied by pain in the abdomen area,
sometimes near the stomach. Pain is not radiating to the
back. Complaints also accompanied by nausea, there is no
vomiting and fever. Patient complaint about abdominal
swell that enlarge slowly since 6 months ago. Abdomen
swell increasingly became hard and there is a lump
growing in the left abdomen. The Patient feel very weak
and had walking difficulty . Appetite and weight of the
patient are decreased, body weight loss is around 19 kg
within 3 months. Patient also complaint about difficulty in
Urinating .
History of high blood pressure and diabetes are denied

Past illness

Medication history

Same illness before (-)

Hypertension and
Diabetes indisputably

Furosemid 40mg

Anamnesis
Family illness history
Hypertension (-)
DM (+) patients
Father
Same illness (-)

Social history
Smoking (-)
Alkohol
consumption (-)

Physical examination
General condition
: Weak
Consciousness
: Compos mentis
Vital signs
BP
HR
T :
RR

: 122/85 mmHg
: 112x /minute, reguler
36,8 0C
: 2x / minute

Body Weight : 34 Kg
Body Height: 150 cm
BMI: 15,1 (underweight)

Physical examination
Head : Normocephal
Hair : black , even distribution , strongly
attached
Eye : anemic conjungtiva -/- , icteric sckleric
-/- , light reflects+/+ isocor.
Nose
: secretions -/- , septum deviation
Ears : secretions-/- ,
Mouth : moist mucose , cyanosis - ,
hyperemic
tounge (-)
Neck : enlargement lymph gland (-)

Physical examination
Thorax (Pulmo)
Inspection : lesion (-), simetric
movement
when statics, and dynamics,
intercostae retraction (-)
Palpation : simetric movement
, Vocal
fremitus left+right
Percution : Sonor in all lung fields
Auscultation : Vesikuler breath sounds
(+), Rhonki (-), wheezing (-)

Physical examination
Thorax (cor)
Inspection : Ictus cordis cannot be seen
Palpation : Iktus cordis palpable
Percussion: heart upper line : ICS II Linea
Parasternal Sin
heart right line : ICS II-III Linea Parasternal
Dextra
heart waist line : ICS V Linea Midclavicularis Sin
Auscultation: HS I-II reguler, gallop (-),murmur (-)

Physical examination
Abdomen:
Inspection: swelling (+) Scar (+), caput medusa (-),
abdomen circumference 72cm
Auscultation: Increased Bowel sound (+) 12x/mnt
Palpation : Tenderness(+) on abdominal field
Liver and spleen are hard to evaluate
Mass from left lumbal region to umbilical , immobile,
uneven surface
Percussion : Tympani on abdominal field, dull on Mass
Ekstremities : All warm, edema (-), pale (-), CRT <
2sec

Laboratory findings
Examination

Result

Normal value

Hb

13.1

13 18 g/dL

Ht

38

40 52 %

Eritrosit

5,8

4,3 6,0 juta/uL

WBC

7910

4800 10800 / uL

Platelet Count

319.000

150000 400000 / uL

MCV

81

80-95 fl

MCH

29

27-32 pg

MCHC

35

32-36 g/dl

Examination

Result

Normal value

SGOT

35

<35

SGPT

19

<40

Urea

45

20-50 mg/dl

Creatinie

0,7

0,5-1,5 mg/dl

Blood Glucose

87

<140mg/dl

Na

125

135-147

Potasium

3,9

3,5-5-0

Cloride

86

95-105

Resume
Pasien came with chief complaint of watery stool more than
5 times since 3 days BHA. The Stool colour are brown,
watery, with slime Complaints accompanied by pain in the
abdomen area, sometimes near the stomach. Patient also
complaints about nausea and abdominal swell that enlarge
slowly since 6 months ago. Abdomen swell increasingly
became hard and there is a lump growing in the left
abdomen. Body weight loss is around 19 kg within 3 months.
Physical examination findings : Increased bowel sounds,
abdomen palpation revealed mass at left abdominal
quadran.
Laboratory findings
Natremia : 125 mmol/L
Cloride : 86 mmol/L

Problems lists
1. Acute Diarrhea
2. Electrolite Imbalance
3. Abdominal mass

Assessment
1. Acute Diarrhea
Ax : Watery Stool , >5times . Slime (+),
Nausea (+)
PE : increased bowel sound, Abdominal pain
Planning :
Diagnosis : Feces examination
Therapy : IVFD RL 500 ml / 8 jam
New Diatab 3 x table PO
Drip Metromidazole 3x500 mg
Ondacentron 3x 4mg

Assessment
2. Electrolite imbalance
Ax : Watery Stool , >5times for 3
days, patient
feel weak
LE : Na 124 mmol , Cl 86 mmol
Planning :
Diagnosis : Electrolite examination after 24
H
Therapy : IVFD RL + KCL 25 Meq/8 jam

Assessment
3. Abdominal Mass
Ax : Abdominal swelling, Hard Mass
around the stomach
PE : Palpable mass left abdominal
quadran, imobile
Planning : Abdominal USG, Biopsy

PROGNOSIS
Quo ad Vitam
: Dubia
Quo ad Functionam : Dubia
Quo ad Sanationam : Dubia