Morning Report

Monday, January 8th, 2018

 Biographical Data
• Name : Ade Febriansyah
• Sex : Male
• Age : 37 years old
• Address : Ulu Timur II
• Occupation : Worker
• Admission : January 6th, 2018
 History Taking
Chief Complaint
Abdominal distension since 1 month before admission
 Anamnesis (cont…)
Riwayat Perjalanan Penyakit
+ 3 months before admission, patient felt that his abdomen
was distended. weakness (+), nausea (+), vomit (-), loss of
appetite (+), black stool (+), dark urine (+). The patient
went to get treatment to Puskesmas and was referred to
RS AK gani. patient got medicines (forgot the name) and
the symptom was decreased
+ 1 month before admission, patient felt that his abdomen
was distended again. swelling of lower legs and testis (+).
Shortness of breathing (+), weakness (+), nausea (+), vomit
(-), loss of appetite (+), black stool (+), dark urine (+). The
patient went to get treatment to Pelabuhan hospital and
was referred to RSMH
 Anamnesis (cont…)
Past Illness History
• There is no history of hypertension
• There is no history of diabetes mellitus
• There is history of hepatitis since 3 months ago
 Anamnesis (cont…)
Family History
There is no history of the same disease in the family
 Anamnesis (cont…)
Riwayat Pengobatan
 Physical Examination
General Examination
Level of conciousness : compos mentis
Blood pressure : 130/80 mmHg
Heart rate : 102 x/minute
Respiratory rate : 24 x/minute
Temperature : 36,7 oC
Physical Examination (cont…)
Head : pale palpebral conjunctiva (+)
Scleral icterus (-)
Palpebra edema (-)

Neck : JVP (5-2) cmH2O

No enlargement of lymph node
 Physical Examination (cont…)
Thorax:
Pulmo : I: Static and dinamic symmetric left=right
P: Stem fremitus at lower lobe is decreased
P: dullnes from ICS IV
A: Vesicular (+) decreased at lower lobe, wheezing (-), rales (-)
Cor : I: Ictus cordis is not seen
P: Ictus cordis is not palpable
P: upper: ICS II right sternal line
right and left: difficult to be determined
A: HR 102x/menit, regular, murmur (-), gallop (-)
 Physical Examination (cont…)
Abdomen : I: distended, distended abdominal veins (+)
P: tense, epigastric pain (-), liver and spleen are difficult to be
determined
P: undulation (+)
A: bowel sounds (+) decrease

Ekstremitas: pale of extremities (+), pretibial edema(+/+)

Additional Examination
 Diagnosis
• Massive ascites ec liver cirrhosis
 Work-up Examination
• USG
• Routine blood test
• Blood chemistry test
 Tatalaksana
NonFarmacological Farmakologi
• Bed rest • Stopper
• O2 3lpm • Inj. Furosemid 20 mg/24 hours
• Diet IV
• Spironolacton 100 mg/8 hours
• Lactulosa 10 ml/8 hours
• Inj Vit K 1 amp/ 8 hours
• Tranexamic acid 1 amp/8
hours
 Prognosis
• Vitam : dubia ad bonam
• Functionam : dubia ad malam
• Sanationam : dubia ad malam