Miftahuljannah S

Clinical Advisor : dr. RR Ignatia Sinta Murti, Sp.PD-KGEH

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* Name : Mr. AK
* Age : 62 YO
* Sex : Male
* Address : Kutai Lama RT. 01 Kukar
* Religion : Islam
* Work : - (Retired since 3 years ago)
* Hospitalized : September, 11, 2016
40 years ago – • Smoker
now • One day one pack

• Alcoholic during 20 years

36 years ago

• App surgery
29 years ago

• Hipertension
15 years ago • Amlodipin 5 mg

• Fracture os femur dextra

14 years ago
 • Epigastrium tenderness
4 months • Untreated
ago • Traditional herbal

• Epigastrium tenderness
4 hours pre •
•
Radiating to the back (scapula)
pain continously
hospitalized • Neusea (-) vomiting (-)

• Emergency room
Sept,11 2016
at 2 pm
Physical Examination
Head and neck
Eye Anemis (-|-) Icterik (+|+)
Neck Cyanosis (-) Lymph node (N)

Thorax
Shape of chest D=S
Using accessory muscles/general respiratory effort
Inspect chest
(-)
Retraction (-)
Trakhea (middle)
Fremitus :
Palpation ( N / N)
( N / N)
Pulmonary ( N / N)
Identify
(sonor / sonor)
Percussion
(sonor/ sonor)
(sonor/ sonor)
Ves Wh Rh
+ + - - - -
Auscultation + + - - - -
+ + - - - -
Physical Examination
Inspect Ictus kordis can’t be evaluated
Palpation Ictus cordis (P)
Cor Cor Left Border= Mid clavicula Line ICS V Sinistra
Percussion
Cor Right Border= ICS IV PSL Dextra
Auscultation S1 S2 single, regular, murmur (-), gallop (-)

Abdomen
Inspect Flat (+), scar (+)
Auscultation BS (+) Normally
epigastrium tenderness(+) , Hephatomegaly (-)
Palpation
Murphy sign (+)
Percussion Timpani , Ascites (-)
Extremities
Superior warm, cyanosis (-), edema (-)

Inferior warm, cyanosis (-), edema (-), deformity femur (d)

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Lab (Sept,11 Value Lab Value
2016)
Haemoglobin 14,7 11-16g/dl Na 139 136-
145mmol/l
WBC 14.800 4.000-10.000mg/dl K 3,6 3,5-5,0
mmol/l
RBC 5.170.00 3.50-5.50 x 106uL Cl 110 98-106
0 mmol/l
Trombosit 241.000 150.000-450.000 µl GDS 155 60 - 150Mg/dl
Hct 42,1 37.0 – 54.0% Ureum 27,9 10-50mg/dL
MCV 81,4 80-100 fl Creatinin 1,2 0,7-1,5mg/dL
MCH 28,4 27-34 pg SGOT 254 M<25 W<31ui
MCHC 34,9 32-36 gr/dl SGPT 103 M<41 W<32 ui
HbsAg NR
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* Cholelithiasis with cholecystitis
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Day 1 (11/9/2016) Day 3 (13/9/2016) Day 4 (14/08/2016)
S
Epigastrium tenderness Epigastrium tenderness Epigastrium tenderness
O
Composmentis Composmentis Composmentis
GCS : E4V5M6 GCS : E4V5M6 GCS : E4V5M6
BP : 130/90 RR:24 BP: 130/80 RR:24 BP: 130/80 RR:22
HR : 72 Temp:37 HR : 74 Temp:36,6 HR : 78 Temp:36,8

Icteric (+/+) Icteric (+/+)

Murphy sign (+) Murphy sign (+)

A
Obs icteric Obs icteric d.3 Susp choledocolithiasis
Dyspepsia Susp cholelitiasis
Susp cholelitiasis
 Day 1 Day 3 Day 4

P IVFD Kaen 3B IVFD Kaen 3B 1000cc/24 IVFD Kaen 3B

1000cc/24 hours hours 1000cc/24 hours
Inj. Ranitidin 1 Inj. Ranitidin 1 ap/12 Inj. Ranitidin 1 ap/12
ap/12 hours hours hours
Inj. Metoclopraid 1 Inj. Metoclopraid 1 ap/ 8 Inj. Metoclopraid as
ap/ 8 hours hours needed
Levofloxacin tab 1 x 500 Levofloxacin tab 1 x
mg (d.1) 500 mg (d.2)

USG abdomen
MSCT abdomen with
(Cholelitiasis suspect contras
IHBD stone with mild
widening CBD)
 Day 9 Day 10 Day 19 Day 24
(19/9/2016) (20/9/2016) (29/9/2016) (04/10/2016)
S Epigastrium Epigastrium Epigastrium Outpatient planning
tenderness tenderness tenderness
O Composmentis Composmentis Composmentis WBC: 7.68
GCS : E4V5M6 GCS : E4V5M6 GCS : E4V5M6 Hb: 12,3
BP: 130/80 RR:20 BP: 120/80 RR:22 BP: 130/80 RR:24 Bil T/D/I: 1,2/0,5/0,7
HR : 74 Temp:37,1 HR : 75 Temp:36,7 HR : 84 Temp:37,1 SGOT: 124
SGPT: 31
Icteric (-/-)
Murphy sign (-) Consult to surgeon

SGOT: 138
SGPT: 315
Bil T/D/I: 2,6/ 1,5/ 1,1
A Cholelithiasis with Cholelithiasis with Post Laparotomy
cholecystitis cholecystitis cholecystectomy
 Day 9 Day 10 Day 19 Day 24

P IVFD Kaen 3B IVFD Kaen 3B Laparotomy

1000cc/24 1000cc/24 hours cholecystectomy
hours Inj. Ranitidin 1
Inj. Ranitidin 1 ap/12 hours
ap/12 hours Inj.
Inj. Metoclopramid 1
Metoclopramid ap/ 12 hours
1 ap/ 8 hours Levofloxacin tab 1
Levofloxacin x 500 mg (d.5)
tab 1 x 500 mg
(d.4)

MSCT abdomen

(cholelithiasis
with
cholesistitis,
renal cyst
dextra, right
minimal pleura
effusion)
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* Name : Mrs. M
* Age : 39 YO
* Sex : Female
* Address : Jl. Soekarno Hatta, Loa janan
* Religion : Islam
* Work : civil worker
* Hospitalized : 18 September 2016
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5 weeks ago
• Hospitalized with 18 September
• Hiperucemia
• Hospitalized the same 2016
• Cholestrol complaint
• icterus • Emergency Room
• App surgery • Abdominal • Abdominal tenderness
tenderness • Neusea + • Palpable mass in the
• Firstly, persistent vomiting + abdominal
pain 4 days
• Intermitten pain
• Gastroscopy
3 months ago • BNO
• ERCP
• USG abdomen • MRCP
• MSCT abdomen with
contras
2 weeks ago
Physical Examination
Head and neck
Eye Anemis (-|-) Icterik (-|-)
Neck Cyanosis (-) Lymph node (N)

Thorax
Shape of chest D=S
Using accessory muscles/general respiratory effort
Inspect chest
(-)
Retraction (-)
Trakhea (middle)
Fremitus :
Palpation ( N / N)
( N / N)
Pulmonary ( N / N)
Identify
(sonor / sonor)
Percussion
(sonor/ sonor)
(sonor/ sonor)
Ves Wh Rh
Auscultation
+ + - - - -
+ + - - - -
+ + - - - -
Physical Examination
Inspect Ictus kordis can’t be evaluated
Palpation Ictus kordis (P)
Cor Cor Left Border= ICS V MCL Sinistra
Percussion
Cor Right Border= ICS IV PSL Dextra
Auscultation S1 S2 single, regullar, murmur (-), gallop (-)

Abdomen
Inspect convex, scar (+)
Auscultation BS (+) Normally
epigastrium tenderness(+) , Hepatomegaly (-) mass
Palpation
(-)
Percussion Timpani , Ascites (-)
Extremities

Superior warm, cyanosis (-), edema (-)

Inferior warm, cyanosis (-), edema (-)

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Lab (Sept,18 Value Lab Value
2016)
Haemoglobin 9,7 11-16g/dl Na 127 136-
145mmol/l
WBC 36.500 4.000-10.000mg/dl K 4,6 3,5-5,0
mmol/l
RBC 3.890.00 3.50-5.50 x 106uL Cl 95 98-106
0 mmol/l
Trombosit 584.000 150.000-450.000 µl GDS 159 60 - 150Mg/dl
Hct 30,0 37.0 – 54.0% Ureum 32,9 10-50mg/dL
MCV 77,1 80-100 fl Creatinin 0,9 0,7-1,5mg/dL
MCH 24,9 27-34 pg HbsAg NR
MCHC 32,3 32-36 gr/dl 112 NR
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Pseudocyts pancreas
Cholelithiasis
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Day 1 (18/09/16) Day 2 (19/09/16) Day 3 (20/09/16)
S Abdominal tenderness Abdominal tenderness Abdominal tenderness
O Composmentis Composmentis Composmentis
GCS : E4V5M6 GCS : E4V5M6 GCS : E4V5M6
BP : 130/80 RR:24 BP: 120/70 RR:24 BP: 120/80 RR:22
HR : 84 Temp:36,7 HR : 98 Temp:36,2 HR : 100 Temp:36,8

Anemis (+/+)
Anemis (+/+) WBC: 30.0
Icteric (-/-) RBC: 3.68
Icteric (-/-)
Palpable mass in epigastrium Hb: 9,6
Palpable mass in epigastrium MCV: 77,3
quadran MCH: 26,1
quadran
MCHC: 33,7
Ht: 28,4
PT: 17,0 PLT: 511

INR: 1,47
A - Pancreas cyts Pseudocyts pancreas Pseudocyts pancreas
Cholelithiasis Cholelithiasis
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Day 1 Day 2 Day 3

P -Inf. KAEN 3B - Inf. KAEN 3B - Inf. KAEN 3B

1500 cc/ 24 h 1500 cc/ 24 h 1500 cc/ 24 h
-Tranfusi PRC 1 - Omeprazole 1
- Metoclopramid kolf ap/ 12h
e inj 1 ap/ -Blood culture - Kalnex 500
12h + check INR mg/ 8h
- Ranitidine inj - Metoclopra - Meropenem
1 ap/ 12h mide inj 1 1gr/ 8h
- Antrain inj 1 ap/ 12h - Sucralfat
ap/ 8h - Ranitidine 10cc/ 6h
- Ceftriaxone inj inj 1 ap/ - Check CBC
2 gr/ 12h 12h
- Antrain inj 1 - ERCP
ap/ 8h Pancreatography
- Ceftriaxone show pancreas
inj 2 gr/ 12h stent migrate to
pancreatic tail.
In pairs stent
bilier DPT 7F 7cm
 Day 4 (21/09/16) Day 10 (27/09/16)
S Abdominal tenderness , neusea, -
vomit
O Composmentis Composmentis
GCS : E4V5M6 GCS : E4V5M6
BP: 120/80 RR:22 BP: 120/70 RR:24
HR : 78 Temp:36,8 HR : 85 Temp: 37

WBC: 17.8
RBC: 3.47
Hb: 8,7
MCV: 77,6
MCH: 25,1
MCHC: 32,3
Ht: 26,9
PLT: 506

A Post ERCP ec necrotic pancreatitis Post ERCP ec necrotic pancreatitis

with pseudocyst pancreas with pseudocyst pancreas
 Day 4 Day 10

P - Transfusion PRC 2 kolf - Home medication :

- Omeprazole 3 ap with Sucralfate syr 3 x 2 cth
SP/ 24h Omeprazole caps 2 x 1
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