MORNING CASE REPORT

August 9th, 2014

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


THERAPHY
Hospitalized
IVFD NaCl 0,9 % 20 dpm
Oxygen mask 5 -6 l
NGT
Regular insulin drip 4 unit/hours untill BS 200 mg/dL, 2 unit/hours
untill BS < 200 mg/dL

PLANNING DIAGNOSIS
- FBS, BS 2 hours postprandial, HbA1c, lipid
profile
- USG
MONITORING
Vital sign
Complaints
Thank you....