Morning Report

January 3rd , 2018

Rosmaniar , 64 y.o, female, FW 15
 Cc:
 Pain at right upper abdomen since 1 day ago

 Present Illness History

◦ Pain at right upper abdomen since 1 day ago, pain come and go
◦ Yellowish eyes (+)
◦ Itchy (+) all over the body
◦ Urinate like tea (+)
◦ Defecation like putty (+)
◦ Abdomen enlargment (-)
◦ Decreased of body weight 9 kg in 1 month
◦ Decreased of appetite (-)
◦ Nausea (-) vomite (+)
◦ Fever (-)
◦ Cough (-)
Past illness History
◦ History of hepatitis (-)
◦ History of DM (+) uncontrolled
◦ History of hypertension (-)

Family illness History

 No family member suffers from a disease like
the patient
Physical Examination
 Consciousness level: CMC

 BP : 140/80

 HR : 88 x/min

 RR : 20 x/minute

 T: 36 oC
 Skin : normal turgor
 Eye
◦ Conjunctiva are anemic -
◦ Sclera are icteric +/+

 Neck
◦ JVP 5-2 cmH20

 Lung:
◦ Inspection: symetric
◦ Palpation: fremitus symmetric
◦ Percussion: sonor
◦ Auscultation: vesicular, rales -/-, wheezing -/-
Cor:
 Inspection: ictus is not seen.
 Palpation: ictus is palpated at 1 finger lateral LMCS
ICS VI (S)
 Percussion:
Left border: 1 finger lateral LMCS ICS VI (S)
Right border: linea sternalis dextra
Upper border: RIC II
 Auscultation: pure rhythm, murmur (-)
 Abdomen:
◦ Inspection: enlargement (-) spider nevi (-) collateral (-
)
◦ Palpation: Hepar palpable 2 finger below arcus
costarum 2 finger below procesus xipoideus, soft,
blunt edge (+),
◦ Percussion: shifting dullnes (-)
◦ Auscultation: bowel sound (+) normal

 Extremities:
◦ Edema -/-,RF +/+, RP -/-, Palmar eritem (-)
X-Ray thoraks
ECG
Laboratory
Hb 12,5 g/dl
WBC 24.900/mm3
Ht 34%
Thrombocyte 510.000/mm3
RBG 404mg/dl
Na/K/Cl 135/3,2/97
Bilirubin total 7,6
Bilirubin Direk 5,7
Bilirubin Indirek 1,9
SGOT 550
SGPT 501
Working Diagnose
 Colestatis Extrahepatal ec tumor abdomen
 DM type II uncontrolled normoweight
 Colesistitis

dd/
Colestatis Extrahepatal ec Choledocolithiasis
Therapy
 Rest/ Hepar Diet II DD 1700kkal
 IVFD Aminofusin : Triofusin : NaCl 0,9% 12 hour/kolf
 Inj Ceftriaxone 2x1gr
 Inj Insulin 3x8 ui (controlled dose)
 UDCA 3x500mg
 Pronalgest sup (when needed)
Plan
 USG Abdomen