liver chirhosis sbp

8/12/2019 Liver Chirhosis Sbp

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Morning Shift Report

Saturday, 17-8-2013

dr.dikara

Physician In Charge:

1A : dr. Dikara, dr. Satria, dr.Niva (Cardio)

1B : dr. Lya, dr. Fajar

II : dr. Sigit

III : dr. Shinta O Wardani, Sp.PD

Summary of Data Base

Male 47 yo/ w.26

Chief complain : black tarry vomiting and black tarry stool

Patient suffered from black tarry stool and black tarry vomiting since 12 hours beforeadmission, about 3-4 spoons, soft, likes petis and also black tarry vomiting 3-4 times,

about 2-3 spoons accompanied with epigastric pain

He also complained abdominal enlargement since 3 month ago weeks ago, he feltenlargment more biger gradually day by day

He already been diagnosed liver cirrhosis since 3 month ago because hepatitis B infectionand routinely control at gastrology out patient clinic, got 3 kinds drugs (spironolcton,

propranolol and furosemide)

History of hospitalized at RSSA about 5 times, with same complained and the last at july2013

He is a seller, have been married, with 2 children He didnt complained about abdominal pain , fever and also shortnessS of breath History of hypertension: - History of diabetes: - History of family:-

Physical Examination

Ward: BP = 130/80

mmHg

PR = 88 bpm,regular , strong RR = 18 bpm Tax : 36,9C

General appearance looked moderate ill GCS 456

Head Pale conjunctiva (+)

NGT insertedclear

Icteric sclera (+)

Neck JVP R + 3 cmH2O 30 degree


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Chest Heart: Ictus invisible and palpable at ICS VI MCL Sinistra

LHM ictus RHM: SLD , S1 S2 single, mur-mur (-)

Lung: Symmetric, SF D=S, normal percussion,

Rh - - Wh - -

- - - -

- - - -

Abdomen Rounded, liver span 5-6 cm, traubes space tympani, undulation test (+)

Sound of bowel (Normal)

Extremities Leg edema -/- , warm acral, eritema palmaris (+)

Laboratory Finding (August 17th

2013 )

Lab Value (Normal) Lab Value (Normal)

Leucocyte 6.930 3.500-

10.000/L

Natrium 134 136-145 mmol/L

Haemoglobine

MCV

MCH

9.0

100.40

33.80

11,0-16,5 g/dl

76-96 fl

26-34

Kalium 4.88 3,5-5,0 mmol/L

PCV 26.70 35-50% Chlorida 111 98-106 mmol/L

Trombocyte 35.000 150.000-

390.000/L

RBS 113 < 200 mg/dl

SGOT 140 11-41U/L Ureum 20.7 10-50 mg/dL

SGPT

Eo/Ba/Ne/Li/

Mo

PPT

Control

INR

60

2.3/0.1/67

.9/22.1/7.

2

16.4

12.6

1.41

10-41U/L

Normal

Creatinine

APTT

-Pasien-Kontrol

1.02

42.6

25.4

0,7-1,5 mg/dL

Prolong


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CUE AND CLUE PL IDx PDx PTx PMo

Male/47 yo/w/26

A

HM since 12 h ago Diagnosed liver

cirrhosis since 3

moths ago

Routine tookomeprazole,

spironolakton, and

furosemide

Abdominalenlargement since 3

month

NauseaPE

BP: 130/80

PR: 88 regular,

strongRR: 18x/min

Tax: 36.9

Undulation test (+)

Liver span 5-6 cm

Palmar eritem (+)

NGTclear

LAB:

Hb:9.0Leu: 6.93

Alb: 2.08

Thrombo: 35.000

OT:140

PT:60

1. Hemateesis

melena

1.1 Ruptur VE

1.2 PUD

1.3 Gastritis

erosiva

Endoscop

y

FastingGL/8h if 1x clear

start liquid diet

6x200ccat ER 1x clear

IVFD NaCl0.9%:D5%

1:115dpm

Inj. Omeprazole 80mg

continue with

Drip 8mg/h until 3days or

stop bleeding

Inj. Metoclopramid 3x10mg

(prn)

Fluid balance -500/24h

S, VS,

urine

prod,

GL

Male/47 yo/w/26

A

Diagnosed livercirrhosis since 3

month ago

Abdominalenlargement

NauseaPE

BP: 130/80

PR: 88 regular,

strongRR: 18x/min

2. Liver

cirrhosis Child

pugh C

2.1 post

necrotic

hepatitis B

infection

2.2 post

necrotic

hepatitis cinfection

endoscop

y,USG

Abdomen

Bed rest

Fluid balance negative

500cc/h

Fluid diet 6x200cc

PO:Spironolakton,

furosemide, propranolol

postponed

S,VS,

sign

hepati

c

enche

palopa

thy


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Tax: 36.9

Undulation test (+)

Liver span 5-6 cm

Palmar eritem (+)

NGTclear

Lab:

HbsAg (+)

Hb: 9.0

OT:140

PT:60

Alb: 2.08

Male/47 yo/w/26

Lab:

Albumin: 2.08

3.

Hypoalbumine

mia

3. 1 dt liver

chirrhosis

3.2

Hypercatabol

ic stateS

Protein

esbach

Treat underlying disease Alb

level

Male/47 yo/w/26

LAB:

PPT: 16.4

Cont:12.6

INR: 1.41

APTT: 42.6

Cont: 25.4

4. Prolong FH 4.1 dt no 2 Transfusion FFP 10cc/kgbw FH,

TRALI

Male/47 yo/w/26

A:

Epigastric pain

Nausea

Hematemesis

melena

PE:

Abdomen rounded

Udulation test (+)

Epigastric tendenerss

Lab:

Hb: 9.0

Leu: 6.930

5. Epigastric

pain+Hemamt

emesis melena

4.1 Dyspepsia

snyd dt no 2

4.2 SBP dt no

2

Acites

analysis

Confirmed diagnosed

Omeprazole as above

S, VS,

PMN

Male/47 yo/w/26

Lab:Hb:9.0

MCV: 100.40

MCH:33.80

6. Anemia MM 6.2 dt no 2

6.3 Def B126.4 Def Folic

Acid

Treat underlying disease

PO:Folic acidB6 3x1

B12 3x1

S, VS,

PMN

liver chirhosis sbp

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