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MORNING REPORT

C3
A 31 year-old female was admitted to R.D.
Kandou Hospital at C3 ward on Sunday , 11th
December 2017

With main complaint: Abdominal enlargement


Patients identity
Name : Mrs PDS
Age : 31 yrs
Sex : female
Occupation : housewive
Education : Senior high school
Ethnicity : Minahasa
Religion : Christian
Present Medical History
Abdominal enlargement since 3 months b.a., patient didnt
complain pain
Patient complain fatigue & general weakness the whole day
while resting and worsen with activity.
Patient have normal appetite although loss of weight + 25 kg
within 6 months
Patient complain bout swollen on both legs since 2 months ago
without decrease in mobility. Patient didnt complain bout pain.
Patient have no complain about shortness of breath while
resting or activity.
Patient consume roasted, canned and preserved food regularly
>3x/weeks.
Patient denied family history diagnose with cancer or the same
disease.
Patient have unregular menstruation cycle, with no complain
bout pain in menstruation, excessive bleeding or white plaque
monthly.
of consuming KB drugs regular since 6 years ago, and recently
with KB injection 6 months ago.
Patient have 2 children in teenage ages alive and healthy
Patient can do self activity within range and have normal
appetite.
Defecating and urinating have no complain.
Past Medical History
History of previous heart, DM, high cholesterol, uric
acid was denied.
History of allergy :
Unknown
History of immunization :
Unknown

Habit history :
Alkoholism (-), Smoking (-)
Family History
None experienced the same illness
General anamnesis ( review of system )
General : abdominal enlargement
Skin :
Head and neck : -
Eye :-
Ear :-
Nose :-
Mouth and throat: -
Respiratory :
Chest :-
Heart :
Abdomen : Abdominal enlargement
Genitalia :-
Extremitas : Leg and foot swelling
Kidney :
Hematology :
Endocrine :
Musculosceletal :-
Physical Examination
GC: Moderate ill Sens : CM
C3:BP: 110/70mmHg, PR 80x/m, RR 18x/m, T 36,8C
ER :BP: 110/70mmHg , N 80x/m, RR 18x/m, T 36,8 C
BW 52 kg, BH 165 cm, BMI 19 kg/m2
Head : conj. anemic (+), scl. icteric(-),
Neck : JVP 5+0 cmH20, lymph nodes enlargement (-), thyroid (-)
Thorax :
Heart :
Insp : IC not visible
Palp : IC not palpable,
Perc : left border: ICS V midclavicullar line
right border: ICS IV parasternal line
Ausc : SI-II regular, murmur (-), gallop (-)
Physical examination
Lung : Insp : Symmetric
Palp : stem fremitus R = L
Perc : sonor
Ausc : vesicular, ronchi -/-, wheezing -/-
Abd :
Insp : Soepel , symmetric, ascites(+)
Palp : Tender, pain (-)
Liver palpable 10 cm b.a.c 5cm below proc.xiphoid ,
lump (-), spleen not palpable
Solid and immobile mass on the adnexa
Perc : Shifting dullness (+)
Ausc : Bowel sound (+) normal
Waist : Pain on CVA exam (-/-)
Extr : inferior: warm, edema (+/+)
RT : Feses +, Blood (-), Mass (-)
Lab Result
11/12/2017 8.30 WITA
Leucocyte 18300 Gamma GT 488
RBC 3.27
Hb 7 Bil.Total 1.74
Ht 37.3%
Platelet 831.000 Bil.Direct 0.82
MCH 21.4
MCHC 31 HCV rapid (-)
MCV 69.1 HbsAg (-)
SGOT 43
SGPT 25
RBS 100
Cl 85.9
K 3.87
Na 121
Ureum 11
Creatinine 0.5
Lab Result
11/12/2017 21.30 WITA
Leucocyte 17300 PT : 17,3/13,2
RBC 3.27 APTT : 42,1/32,9
Hb 7.2
Ht 37.3%
Platelet 818.000
MCH 21.4
MCHC 31
MCV 69.1
Albumin 2.49
Serum Iron 11
TIBC 140
Ureum 10
Creatinine 0.6
Calcium 8.84
Phosphor 3.6
USG abdomen 11/12/2017
Problem List
No CM : 519497 Age : 31 y.o
1. Main complain:
Abdominal enlargement
2. Anamnesis:
Abdominal enlargement
Fatigue & general weakness
3. Physical examination:
GC: Moderate ill Sens : CM
C3:BP: 110/70mmHg, PR 80x/m, RR 18x/m, T 36,8C
Head : conj. anemic (+), scl. icteric(-),
Abd :
Insp : Soepel , symmetric, ascites(+)
Palp : Tender, pain (-)
Liver palpable 10 cm b.a.c 5cm below proc.xiphoid ,
lump (-), spleen not palpable
Solid and immobile mass on the adnexa
Perc : Shifting dullness (+)
Extr : inferior: warm, edema (+/+)
Roentgen
Roentgen INTERPRETATION
Roentgen Componen Interpretation
Identity Same
KV Normal
Symmetric Symmetric
Trachea Middle
Diaphragma Normal
Sinus Costophrenicus Sharp
Sinus Cardiophrenicus Sharp
Bone Intact
COR CTR 9.8/21= 46%
Pulmo Parenchym Patch (-)
CONCLUSION : Normal
ECG : Normal sinus rhythm, 75x/min
ECG INTERPRETATION
ECG components Interpretation Value
Rhythm Sinus Sinus Rhythm
Speed / HR (times/mnt) 75x/min 1500/R-R
Axis Normal Normal / RAD / LAD
Morphology P wave 0,10 sec Lead II : Duration 0.10, Height 2.5
PR Interval 0,20 sec 0,12 0,20
QRS complex duration 0,08 sec 0,05 0,11``
ST segmen Normal Normal / Elevated / Depressed
T wave Normal Normal / abnormal
QT Interval 0,40 sec cQT = QT interval / vR-R Interval
U wave Absent Appear / not appear
CONCLUSION : Normal sinus rhythm, HR 75x/m
Karnofsky scale 80
1+2+1+3+1
CTP Class B (1 year survival 45%, 2 year survival
35%)
APRI SCORE 0.16
Thrombocyte 831.000
SGOT 43
No Problem List Plan Dx Plan Tx Non pharm tx Plan Monitoring

1 Abdominal
enlargement.
Uric Acid o
Treat primary Educate the Observation for
disease family about vital signs, body
C3:BP: 110/70mmHg, CT-Scan with the condition of weight, waist
PR 80x/m, RR 18x/m, contrast the patient and circumference,
T 36,8C plans ahead. decrease of
Head : conj. anemic Tumour Marker consciousness,
(+), scl. icteric(-),
CEA,AFP, Ca 125 bleeding
Abd :
Insp : Soepel , B-HCG
symmetric,ascites(+)
Palp: Tender, pain (-) Liver BIopsy
Liver palpable 10
cm b.a.c 5cm below
proc.xiphoid , PET SCAN
lump (-),
Solid and immobile
mass on the adnexa
Perc: Shifting
dullness (+)
sound (+) normal
USG abdomen :
Multiple nodule on liver
Ascites
Mass on the
uterus/ovarium
Multiple nodular
Hepar ec
Metatase dd
hepatome dd
Hepatic
Cholangio
Carcinoma
No Problem List Plan Dx Plan Tx Non pharm tx Plan Monitoring

2 Fatigue
Eye : Sclera Icteric (+)
Blood Smear o
Treat Primary Educate the Observation for
BMP if needed disease family about the vital signs
Hb 7.2 condition of the
MCV 69.5
MCH 21.8
Sulfas Ferrous patient and plans
MCHC 31.3 tab. 250mg/12 hr ahead.
SI 11
TIBC 140 Transfusion PRC II
Anaemia bag
Hipochromic
Microcyter ec
Iron Deficiency dd
Chronic Disease

3 Enlarge abdoment (-) VIP albumin 3x2 g


Swollen both leg Albumin 25% fls
Abdoment 50cc
:Ascites(+)
Ext Inferior:
Edema (+/+);
Albumin = 2.54
0,8x(3,2- 2,49) x 60=
28.4 gram protein

Hypoalbuminemia
No Problem List Plan Dx Plan Tx Non pharm tx Plan Monitoring

4 Laboratory:
Thrombist : 831.000
Blood Smear o
Treat Primary Educate the Observation for
BMP if needed Disease family about the vital signs
PT 17.7/13.2 condition of the
APTT 42.1/32.9
patient and plans
ahead.
Thrombositosis
Reactive

5 Na : 124 meq Electroylte 0,6 x 50 x 14 = Educate the Observation for vital


Hyponatremia control 420 mEq family about the signs
condition of the
Salt Capsule 3x1 patient and plans
ahead.
Conclusion
Has been reported A 31 year-old man
admitted to R.D. Kandou Hospital at C3 ward
on 11th December 2017 with main complain
abdominal enlargement, from anamnesis,
physical examination an laboratory diagnosed
with Multiple nodular Hepar ec Metatase dd
hepatome dd Hepatic Cholangio Carcinoma +
Anaemia Hipochromic Microcyter + Hypo Na +
HypoAlbuminemia + Thrombosis Reactive
Prognosis
Ad Vitam : Dubia ad Malam
Ad Functionam : Dubia ad Malam
Ad Sanationam : Dubia ad Malam
Thank You