March22nd , 2018

DUTY REPORT
R, 48 YO, MALE, FW 15
 Chief Complaint:
 Unable to sleep at day time
 Present Illness History
 Stomach getting bigger since 1 month ago, pain on the right
stomach, come and go
 Decrease of appetite since 1 month
 Weight decrease ± 15 kg in the last 1 months
 Nausea (+), vomit (+) 10x/day ½-1/3 cup, since 2 weeks ago
 Cough (-), breathlessnes (-)
 No fever
 Leg swelling since 2 weeks ago
 No black stool
 Tea like urine (+)
 Patient was hospitalized in muarabungo for 4 days with liver
cirrhosis and transferred to M Djamil
 Sleep pattern disorder (+)
Past illness history
 History of hypertension (-)
 History of DM (-)

 History of yellow fever (-)

 History of kidney disease (-)

PHYSICAL EXAMINATION
 Consciousness level: CMC

 BP : 130/80 mmHg

 HR : 110 x/minute

 RR : 22 x/minute

 T: 37,5º C
 Eye
 Anemic conjunctiva (-)
 Icteric sclera(+)
 Neck
 JVP 5-2 cmH20
 No lymph enlargement
Lung:
 Inspection: statically & dynamically symmetric sin=dextra
 Palpation: fremitus equal on both side
 Percussion: sonor
 Auscultation: vesicular, rales -/-, wheezing -/-

 Cor:
 Inspection: ictus is not seen.
 Palpation: ictus is palpated at 1 fingermedial LMCS ICS V
 Percussion:
 Left border: 1 finger medial LMCS ICS V
 Right border: linea sternalis dextra
 Upper border: ICS II
 Auscultation: regular, murmur (-)
 Abdomen:
 Inspection: enlargement (+)
 Palpation: Spleen on S1
 Percussion: shifting dullness (+)
 Auscultation: bowel sound (+) N

 Extremities:
 Oedema pretibia +/+
 Physiologic Reflex +/+
 Pathologic Reflex -/-
LABORATORY

Hb 14,2 gr/dl

Ht 42

WBC 10.780/Mm3

Platelet 161.000/Mm3
WORKING DIAGNOSE

 Extrahepatal cholestasis ec susp.

choledocolithiasis with biliary cirrhosis and
hepatic encephalopathy grade 2

DD/
Extrahepatal cholestasis ec pancreatic caput
carcinoma
Extrahepatal cholestasis ec liver cirrhosis
THERAPY
 Rest/ DH II
 IVFD Comafusin Hepar:Triofusin:NaCl
0,9% 1:1:1 8 hrs/kolf
 Lactulax syr 3xC1

 Spironolakton 1x100mg

 Madopar 3x1
PLAN

 USG Abdomen
 Liver function test

 Electrolytes level