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AFTERNOON REPORT

5 AUGUST 2017
Initial : IWW
Age : 55 yo
Gender : Male
Ethnicity : Balinese
Religion : Hindu
Address : Jl. Gunung Guntur gg c3 DPS
Marital Status : Married
Med. Record : 17035344
ToA : 23 August 2017, 10.00
Chief complain: Epigastric pain
Present History:
Patient male 55 yo come to emergency department complaint about
epigastric pain since yesterday BATH. The pain feel like squeezing but
didnt thru the back. Pain said spread in all region of abdomen. Pain
doesnt relieve by changing position
Patient also complaining about nausea since yesterday but not until
vomit. Urination like tea colour since 7 months ago but disappear
when getting medication. Yellow eye (+), fever (-), Melena (-)
Past History illness:
Patient Antending to the hospital in Wangaya with the same
complaint since 7 months ago. In wangaya hospital, patient said get
USG and Endoskopi examination. They said there something
abnormal in liver and inflammation gaster
Family history:
Theres no family with the same complaint
Social history:
Smoking and alcohol denied
Status Present:
Physical appreance : moderate ill
GCS : Compos mentis
Blood Pressure : 90/60
RR : 24x/ minute
PR : 122X/ minute
Temp: : 36,5 0C
Bw : 60 kg
H : 170 cm
BMI : 20,7 kg/m2
Eyes : anemis(-/-); icterus (+/+), reflex pupil(+/+), oedema palp. (-/-)

ENT : Tonsils T1/T1; pharyngeal hyperemia (-); lip cyanosis (-),


epixtasis (-), gums bleeding (-).

Neck : JVP PR + 0 cmH2O;


lymph node enlargement (-)
Thorax : Simetris
Cor
Inspection : Ictus cordis unseen
Palpation : Ictus cordis unpalpable
Percussion :
UB : ICS II S
LB : MCL S ICS V
RB : PSL D
Auscultation : S1 S2 single regular, murmur (-)
Po
Inspection : Symetric (static and dynamic)
Palpation : Vocal Fremitus N/ N
Percussion : sonor/sonor
Auscultation : vesicular +/+ , Rh -/-, wh -/-
Abdomen :
Inspection : Distention (-)
Auscultation : Bowel sounds (+) normal
Percussion : Tympani
Palpation : Liver and spleen not palpable, liver span 10
cm, traube space timpani, shifting dullness (-)

Extremities: Warm +/+; oedema -/-, ulkus -/-


LFT:
Bilirubin Total : 10,9 (H)
Direk : 8,9 (H)
Indirek : 1,25
ALP : 708 (H)
SGOT : 140 (H)
SGPT : 274 (H)
GGT : 1447 (H)
PT : 6,6 (L)
Albumin ; 4,1
BUN : 13
Sc : 0,91
Na : 132 (L)
K : 3,6
GDS : 117
CBC
(23 August 2017)
Rontgen Paru
Cor : CTR > 65 %
Pulmo : Hiperaerasi kedua paru.
tak tampak infiltrat/nodul.
Corakan bronchovaskuler normal
Sinus pleura kanan kiri tajam
Diaphragma kanan kiri normal
Tulang-tulang : tidak tampak
kelainan
Kesan:
Susp. Cardiomegaly (kurang
inspirasi dan AP)
Asessment

Cholestasic jaundice 3ec susp CBD stone dd tumor ampula vater dd


cholingioma carcinoma
Chronic liver disease Trombositopenia
Planning
Initial treatment:
Cholestatic jaundice:
IVFD NS; d10% : aminoleban = 1:1:1 = 20 rpm
UDCA 3x 250 mg IO
Pentidin 25 mgr @ 8 hours if vas > 6
USG Abdomen
Susp chronic liver disease:
Fibroscan, USG abdomen
Planning
Planning Diagnostic:
USG abdomen
Fibroscan
HbsAg, anti HCV

Monitor:
Vital sign, keluhan
LFT @5 jam