INTERNA DEPARTMENT

PATIENT MEDICAL DATA

IDENTIFICATION

Reg/MR Number : RI 16019625/ 962238

Name
: Mr. EBR
Age
: 48 yo
Work
: Entrepreneur
Adress
: Tungkal Muara Enim
Admission
: July, 19th 2016 (Time 14.00 WIB )
Melati 2

CHIEF COMPLAIN
(Auto
(Auto dan
dan Alloanamnesis)
Alloanamnesis)

Eyes became yellowish since 2 days before admission

HISTORY OF THE PRESENT ILLNESS

Since a week before admission
an 48-year-old Enimness male, suffered epigastric pain, spread
to the upper right quadrant and back, colicy like, didnt increase
when he consumed foods. His symptoms were not associated
with vomiting. She denied chest pain, back pain, shortness of
breath, headache and febris. He went to the Hermina hospital
and consulted to the physician. He got a USG, MRCP, Thorax
photo, ECG and medical treatment. From the examined, the
physician say the there was a stone in the gall bladder and the
CBD. After 5 days in the hospital, his eyes and became
yellowish, his urine like a strong tea. He was refered to the
RSMH hospital for another supporting examination.

PAST MEDICAL HISTORY

Hipertention suffered since two years ago, not routine control

Diabetes Mellitus is refused
Gall stone suffered 6 months ago
Hepatitis is refused
Abdominal trauma is refused

SOCIAL HISTORY

Entrepreneur, history with tobacco since 30 yeasr ago, one

pacs per day, alcohol consumption rarely.

FAMILY HISTORY

Non-contributory

PHYSYCAL EXAMINATION
(BASIC EXAM)
Constitutional : Compos mentis
Airway : Patent
BP : 160/ 90 mmHg
Pulse rate : 64 time/min, regular rate and rhythm
RR : 20 time/min, abdominothoracal type
Temp: 36,7 C
VAS : 4
Stature : 163 cm
Body weight : 55 kg
RBW: 95% (normoweight)
PS : 80%

PHYSICAL EXAMINATION
(DETAILED EXAM)
HEENT :

Visual acuity normal, anemis conjunctiva (-),

icterik sclera (+), PERRL, midface normal, nose

normal
Neck

:Trachea midline, no JVD, no goiter, no

lymphadenopathy

PHYSICAL EXAMINATION
(DETAILED EXAM)
Respiratory Exam :
Normal expiratory ratio, no wheezing, no rales, no rhonchi,
normal work of breathing, speaking full sentences, egophony
normal, bases of lungs clear, no chest wall tenderness, no
crepitus.

Cardiovascular Exam :
No murmurs, rubs or gallops, PMI dime sized, no lifts, HR 64
x/min regular.

PHYSICAL EXAMINATION
(DETAILED EXAM)
Abdominal Exam :
Soft,

Murphys

sign

positive,

mild-moderate

diffuse

tenderness, no rebound guarding, no peritoneal signs, no

collateral vein, tymphani, liver just palpable with no
splenomegaly, no mass or swelling, no CVA tenderness.

Extemities Exam :
Normal skin perfusion, joints non-tender, no joint effusion, no
deep vein tenderness, no rash, normal pulse.

BEDSIDE
ELECTROCARDIOGRAPHY, 19-07-2016

Sinus rhythm, HR 64x/mt, LAD, Normal P wave, PR interval 0.016 s,

QRS comp 0.06 dtk, R/S at V1 < 1, S at V1 + R at V5/V6 <35, ST-T
Change (-).
Conclusion: LAD

LABORATORY FINDING (19-07-2016)

Hematology
13.3 mg/dL
Eritrocyte 4.40 juta/m3
Leukocyte 11.8 /mm3
Hematocryt
39 %
Trombocyte 297 L
DC
0/3/64/24/9
BSS
96 mg/dL

Chemistry

Hb

SGOT

135 U/L
SGPT 180 U/L
Tot Bilirubin
10.90 mg/dL
Bil Direct 9.13 mg/dL
Bil Indirect 1.77 mg/dL
Ureum 30 mg/dL
Creatinin 0.77 mg/dL
Calsium
8.4 mEq/L/dL
Sodium
140 mEq/L
Potassium
3.6 mEq/L

LABORATORY FINDING (19-07-2016)

Faal Hemostasis
PT

11.4 (13.00)
APTT 28.3 (29.3)
INR
0.85
Fibrinogen 520 (313)
D-dimer 3.55
Anti HCV Non reaktif
Anti HIV Non reaktif
HBsAg Non reaktif

RADIOLOGY
THORAX PHOTO (11-07-2016)

Photo is well (PA position)

Simetrical
Trachea mid line
Bone and soft tissue is well
Intercostal space normal
Sharp Costophrenicus sinus
Diafragma tenting (-)
CTR < 50%
Lung parenchime : normal

Conclusion:
Normal thorax

RADIOLOGY
Abdominal USG (12-07-2016)

Conclusion:
1. There is chronic
cholecystitis with multiple
stone in the gall bladder
2. Obtruct in the CBD
3. 5.5 cm cyst in the left
Kidney

RADIOLOGY
MRCP and MRI, 15-07-2016

RADIOLOGY
MRCP and MRI, 15-07-2016

RADIOLOGY
MRCP & MRI (15-07-2016)

Conclusion:
1. Hepatomegaly and fatty liver, can be diffuse parenchimal
disease
2. Cholecystitis with dilated choleducal duct, hepaticus duct,
intrahepatic biliarry duct, cyctic duct et cause multiple stone at
the distal choleducal duct
3. Left kidnet cyst

DIAGNOSIS
1.
2.
3.
4.

Icterus Obstructive ec CBD Stone

Cholecystitis
Cholelithiasis
Hipertensi stage II

TREATMENT
Non - medicamentosa
Bedrest
Low fat dietary and low salt
Education

TREATMENT
Medicamentosa
Cefixime 2 x 100 mg PO
Lansoprazole 2 x 20 mg PO
Valsartan 1 x 80 mg
PO
Amlodipine 1 x 5 mg PO
Ketoprofen supp PRN
Rebamipide3 x 100 mg PO

PLANNING

Urinalysis
INR, PT, APTT, Fibrinogen, D-dimer
HBsAg, Anti HCV, Anti HIV
ERCP
GI consult

PROGNOSIS
Quo ad vitam
: dubia ad bonam
Quo ad sanationam : dubia ad bonam
Quo ad functionam : dubia ad bonam

TERIMA KASIH