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This morning report provides biographical and clinical information about a 37-year-old male patient admitted to the hospital with abdominal distension. The patient has a history of hepatitis and abdominal swelling for the past 3 months. On physical examination, the patient has abdominal distension and ascites. A diagnosis of massive ascites due to liver cirrhosis was made based on the ultrasound and blood test results. The patient is being treated non-pharmacologically with bed rest and oxygen, and pharmacologically with diuretics, lactulose, vitamins, and other medications. The prognosis is guarded due to the possibility of poor functional status and sanation.
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Case patient interna stage by fellow medical student
This morning report provides biographical and clinical information about a 37-year-old male patient admitted to the hospital with abdominal distension. The patient has a history of hepatitis and abdominal swelling for the past 3 months. On physical examination, the patient has abdominal distension and ascites. A diagnosis of massive ascites due to liver cirrhosis was made based on the ultrasound and blood test results. The patient is being treated non-pharmacologically with bed rest and oxygen, and pharmacologically with diuretics, lactulose, vitamins, and other medications. The prognosis is guarded due to the possibility of poor functional status and sanation.
This morning report provides biographical and clinical information about a 37-year-old male patient admitted to the hospital with abdominal distension. The patient has a history of hepatitis and abdominal swelling for the past 3 months. On physical examination, the patient has abdominal distension and ascites. A diagnosis of massive ascites due to liver cirrhosis was made based on the ultrasound and blood test results. The patient is being treated non-pharmacologically with bed rest and oxygen, and pharmacologically with diuretics, lactulose, vitamins, and other medications. The prognosis is guarded due to the possibility of poor functional status and sanation.
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