Morning Report

Night Shift
Saturday, March 3rd 2018
Identification
Name : Mr. MH
Sex : Man
Age : 48years old
Address : Kemas Rindo, Kertapati
Job : Security
Admitted to Hospital: March 3rd 2018
 History Taking
Chief Complain:
Heavier shortness of breathing since 1 day before admitted to hostpital

Additional Complain:
The stomach grow bigger

Summary of Present Illness:

± 6 months before admitted to hospital, patient feel his stomach grow bigger than normally,
nausea (+), vomiting(-), heartburn (+), uncomfortable of the stomach (+) after eat food,
chest pain(-),fever (-), shortness of breath (-). Urinate like tea (-), defecate more
frequently/diarrhea >3x/days with brown colour. Patient go to a shaman and the man said
that the patient just get illness because of someone make it. The shaman give him a glass of
water for medication. Patient trust the shaman and didnt go to the doctor.
± 2 months before admitted to hospital, patient feel his stomach grow up more bigger than
before, nausea (+), vomiting(-), heartburn (+), uncomfortable of the stomach (+) after eat
food, chest pain(-),fever (-), shortness of breath (+). Urinate like tea (+), defecate like
“cincau” with black colour like soy sauce. Patient also fell his body being yellow. Patient go
to the another shaman and the man also said that the patient just get illness because of
someone make it.
 ± 1 week before admitted to hospital, patient feel his
stomach grow up more bigger than before, tense (+), nausea (+),
vomiting(-), shortness of breath (+), wheezing (-), not affected by
activity and emotion. Cough (+),Chest pain denied Urinate like
tea (+), defecate like “cincau” with black colour like soy sauce >
3x/day. Decrease of appetite (+) decrease of body weight(+), The
patient go to another shaman, this time the shaman suggest him
to the internist doctor.
1 day before admitted to hospital, patient felt heavier
shortness of breathing, not affected by activity and emotion,
cough (-), mengi (-), the eyes are blazing (-), fatigue (+), big
stomach (+), tense (+), chest pain (-). Patient went to emergency
of RSMH and treated by the internist. Now he treated in the
internist ward.
Habit history:
• Smoking (+) ±40 years, 10 cigarettes per day
• Drinking alcohol in the past (+)
• Use drugs denied
• Consumed drug for decrease pain (+)
• Consumed herb denied
• Transfusion in the past denied

Past Illness History:

• The same illness before (-)
• Hepatitis denied
• Hipertention(-)
• Diabetes mellitus(-)
• Asthma(-)

Illness in Family History:

-
Physical Examination
General Condition (In the Ward)
Sens : compos mentis
BP : 110/70mmHg
HR : 96 x/m
T : 36.8oC
RR : 28 x/menit
Specific Examination
Head and Neck
Head: Pale conjunctiva +/+, Icteric sclera +/+
Mouth : Cheilitis (-), gum bleeding (+), sianosis (-)
Neck : JVP (5+2) cmh20, lymph gland enlargement (-)

Pulmo
I: static and dynamic  symmetric, wide ribs widened, spider nevi (-),
ginekomastia (-)
P: stem fremitus right = left
P: hipersonor at whole lung
A:vesicular (+) normal, rhonki -/-, wheezing -/-
Jantung
I: Seen ictus cordis
P: Palpable ictus cordis, thrill (-)
P: top heart border ICS II, right heart border LSdextra, left heart
border LMC ICS VI
A: HR:96 x/m murmur (-), gallop (-)

Abdomen
I: convex, caput medusa (-)
A: bowel sound decrease (2x in one minutes)
P: tense, liver and lien difficult to evaluate
P: dull, shifting dulness (+), undulate (+)
Upper and Lower Extremities
Warm Acral
Edema upper extremities -/-
Edema lower extremities +/+
Palmar eritema (+)
Additional Examination
Pemeriksaan Laboratorium Darah
Hb: 10,2 Na: 134
RBC:3.56 K: 4.4
WBC: 7600 HBsAg : Reaktif
Ht: 29%
PLT: 224.000
RDS-CV: 20.30
Diff. count: 0/1/67/19/13
SGOT/SGPT: 114/44
Total bilirubin 3.69
Bilirubin Direk : 3.41
Bilirubin indirek : 0.28
Total protein : 7.0
Albumin : 3.3
GDS: 90
Ur/Cr:29/0.74
Ca: 8.4
Physical examination
Thorax roentgen
Diagnosis
Temporary Diagnosis:
Cirrhosis hepatis decompensate with massive ascites
Chronic B hepatitis virus

Differential Diagnosis:
Cirrhosis hepatis decompensate with massive ascites
Hepatoselular adenoma
Hipertensi portal
Examination Plan
• Routine blood test (Hb, Ht, RBC, WBC, trombosit, diff count)
• Chemistry blood test (SGOT, SGPT, Ureum, Creatinin, Sodium,
Na, Potassium.
• Albumin test
• Abdomen USG
• CT scan abdomen
 Therapy
Non Pharmacologic: Pharmacologic:
• Bed rest • IVFDNS:D5% aminofusingtt xx/menit
• Education • Spironolacton 100 mg/8 h iv
• O2 2 LPM (via nasal cannula) • Furosemide 20 mg/24 h iv
• Omeprazole 40 mg/12 h iv
• Lactulosa 10cc/6 hpo
• curcuma 1 tab/8 h po
Prognosis
Quo ad vitam: dubia ad malam
Quo ad functionam: dubia ad malam
Quo ad sanationam: dubia ad malam