- The patient is a 49-year-old male admitted with complaints of diarrhea, decreased consciousness, and abdominal distension.
- Physical examination found decreased consciousness, abdominal distension with shifting dullness, and signs of liver cirrhosis.
- Initial labwork showed anemia, thrombocytopenia, and signs of liver dysfunction.
- The leading diagnoses are acute diarrhea likely due to bacteria or protozoa, cirrhosis with complications of hepatic encephalopathy and ascites, and normocytic anemia related to the chronic liver disease. Treatment plans include rehydration, antibiotics, diuretics, and blood transfusion.
- The patient is a 49-year-old male admitted with complaints of diarrhea, decreased consciousness, and abdominal distension.
- Physical examination found decreased consciousness, abdominal distension with shifting dullness, and signs of liver cirrhosis.
- Initial labwork showed anemia, thrombocytopenia, and signs of liver dysfunction.
- The leading diagnoses are acute diarrhea likely due to bacteria or protozoa, cirrhosis with complications of hepatic encephalopathy and ascites, and normocytic anemia related to the chronic liver disease. Treatment plans include rehydration, antibiotics, diuretics, and blood transfusion.
- The patient is a 49-year-old male admitted with complaints of diarrhea, decreased consciousness, and abdominal distension.
- Physical examination found decreased consciousness, abdominal distension with shifting dullness, and signs of liver cirrhosis.
- Initial labwork showed anemia, thrombocytopenia, and signs of liver dysfunction.
- The leading diagnoses are acute diarrhea likely due to bacteria or protozoa, cirrhosis with complications of hepatic encephalopathy and ascites, and normocytic anemia related to the chronic liver disease. Treatment plans include rehydration, antibiotics, diuretics, and blood transfusion.
- The patient is a 49-year-old male admitted with complaints of diarrhea, decreased consciousness, and abdominal distension.
- Physical examination found decreased consciousness, abdominal distension with shifting dullness, and signs of liver cirrhosis.
- Initial labwork showed anemia, thrombocytopenia, and signs of liver dysfunction.
- The leading diagnoses are acute diarrhea likely due to bacteria or protozoa, cirrhosis with complications of hepatic encephalopathy and ascites, and normocytic anemia related to the chronic liver disease. Treatment plans include rehydration, antibiotics, diuretics, and blood transfusion.
Interna : Melati ward 8 patients Kenanga ward 14 patients Total patients from 07 pm 04 am : 3 New-in patients Male/49 yo/EH Male/ yo /CKD + DM type 2 Female/25 yo/DF Anamnesis (aloanamnesis) Male / 46 yo Chief Complaint: Diarrhea Patient suffered from watery diarrhea since 2 days before admission with frequency more than 5 times daily, consist of water, blood (-), mucus (-), Patient also complained decreased of consciousness since 1 day before admission. Patient suffered from abdominal distension since 4 months ago and it getting worse since 3 day before admission. Anamnesis (aloanamnesis) Patient had history of chirrosis hepatis since 3 months ago and hospitalized once because of asites Patient just consumed discharge medication and never controlled to the doctor Physical examination BP = 120/70 mmHg HR = 64x, reguler RR = 22 tpm T ax 36,4 C
General appearance : looked severe ill GCS E3V5M6
Head anemic (+/+) icteric (-/-)
Neck JVP 3 cm H2O
Thorax Cor Wnl
Pulmo Simetric, SF D = S SS v v Rh - - Wh - - SS v v - - - - DS v v - - - -
laboratory examination Blood Lab Value Leucocyte 9.000 3500;10000/L Eritrocyte 2,89 3,50-5,50 Haemoglobi 8,2 11,5-16,5g/dl ne Hematocrite 26,2% 35.0-55.0% Thrombocyt 116.00 150000- e 0 400000/L MCV 90,5 75-100 MPV 8,4 8,0-11 MCH 29,9 25-35 SGOT 25 40 u/l SGPT 13 41 u/l RBS 62 100-180 mg/dl Ureum 31 15-45 mg/dl Creatinin 1,56 0,9-1,3 mg/dl Albumin CXR 15/01/2017 CXR 16/02/2017 Taken on 16th February 2017 Identity : Mr. T, 49 yo PA position, Symmetric Soft tissue and bone normal ICS D/S : normal Trachea in the middle Diaphragma: Dome shaped Costophrenicocostalis Dextra & Sinistra normal Costophrenicokardialis dextra & sinistra normal
Cor : site normal Size <50%, boot shaped heart,
Pulmo : normal
Concl: CXR normal
ECG 16/02/2017 ECG 16/02/2017 Sinus Rhythm, regullar HR : 60 bpm Axis frontal : normal horizontal : clockwised P-R interval : 0.2 QRS complex : 0,08 QT interval : 0,32 T inverted in lead v1-v2 Conclusion: normal sinus rhythm HR 60 bpm with ischemic in anteroseptal (lowseptal) CUE AND CLUE PROBLEM INITIAL PLANNING PLANNING PLANNING LIST DIAGNOSE DIAGNOSE THERAPY MONITORIN G
Male / 49 yo 1. Acute 1.1 Electrolite Loperamid VS
Ax: diarrhe Acute Stools loading 2 Complai Watery a dysentric examinatio tab, next 1 n diarrhea (+), diarrhea n tab each bloody 1.1.1 Stool defecation patches on Bacteria Culture and Mollagit 4x2 feces (-), 1.1.2. sensitivity tab history of Protozoa test Azythromici fever (-) on n 3x500 mg the first day p.o for 3 of illness, 1.2 Acute days. increased watery thirsty (+) diarhea
PE: Increased of bowel sounds CUE AND PROBLEM INITIAL PLANNIN PLANNING PLANN CLUE LIST DIAGNOSE G THERAPY ING DIAGNOS MONIT E ORING Middle-aged 2. DOC 2.1 GDS 1. Inj. VS male/ 49yo Hipoglikem Dekstrose 40 DOC ia % 2 ampul PE: 2.1.1 drug 2. IVFD D 5 % GDS: 62 induce 20 tpm g/dl 2.1.2 low intake Lipid 2.2 profile 1.Dietary salt cirrhosis Albumin restriction hepar Globulin 2.High Protein 2.2.1 SGOT Diet ensefalopa SGPT 3.Spironolact ti Bilirubin one 1 x 100 hepatikum mg po 4.Furosemide 2x 40 mg iv 5.Propranolol 2x20 mg CUE AND CLUE PROBLEM LIST INITIAL PLANNING PLANNING THERAPY PLANNING DIAGNOSE DIAGNOSE MONITORING
Middle- 3. 2.1 Chronic - Blood Confirm Dx
aged Normochrom disease smear VS male/ normocytic (Anemia of + - Blood complain Anemia Inflamation) reticul transfussion 49yo 2.2 Accult ocyte CBC after Blood loss count finish the - Faece blood PE: s transfussio Conjunctiv analys n a anemis is + Hb : 8.2 Occult blood exami nation CUE AND PROBLE INITIAL PLANNIN PLANNING PLANNI CLUE M LIST DIAGNOSE G THERAPY NG DIAGNOS MONITO E RING Middle- 4. Asites 1.1Cirrhosi 1.Urinalisa 1.Dietary salt VS aged Male/ s hepar restriction Complai 49 yo 1.1.1 2.Abdomi 2.Spironolactone n Ax: hepatic nal 1 x 100 mg po abdominal failure ultrason 3.Furosemide 2x distention 1.1.2 portal ography 40 mg iv hypertensi 4.Propranolol PE: on 2x20 mg Dystention shifting dullness (+), HGB 8.2 Present Condition BP : 120/70 HR : 82 RR : 20 T : 36,2 GCS 14 THANK YOU
