Duty Report

Friday, October 3rd 2014

dr. Nina Nur Arifah
Physician
IA
: dr.
IB
: dr.
II
: dr.
III
: dr.

in charge:
Nina, dr. Daya, dr. Indra
Etik, dr. Hengky, dr. Betty
Yuni
Sri Sunarti ,SpPD

Summary of Database:
Mr. Misto, 55 yo, W. 22
Anamnesis:
Chief complaint: bloody vomiting
Patient suffered from coffee ground vomiting since 4 hours before admission, the
volume were about 5 glasses each, 4 times. It was preceeded by nausea.
Patient suffered from black-tarry stool about 2 days before admission, 1 time, about 3-4
spoonful. Then the black-tarry stool stopped 1 day before admission and now hes
having constipation.
Patient felt difficult to sleep since 3 days before admission.
This is the third hospitalization. Patient had the same complaints since 5 months ago.
He went to private hospital and hospitalized for a week. He undergone endoscopy and
he was diagnosed having liver disease and got medications: spironolacton and
propranolol. The last time he consumed the medications was about 3 days ago. The
last hospitalization was about 20 days ago. He didnt know which hepatitis he has (B or
C).
Patient is a construction worker, married and had 3 children. He was a heavy smoker
for 20 years, 12x/day but already stopped since 5 months ago.
Physical Examinations
ER BP = 60/palp
Ward BP = 80/60
mmHg on NE

ER PR = 118 bpm, RR = 16 bpm

Tax : 37.3 C
regular, strong
Ward PR = 70 bpm,
regular, strong
General appearance looked moderately ill
GCS 456
Head
Pale conjunctiva (+)
Icteric sclera (-)
Neck
JVP R +2 cmH2O 30 degree, lymphnode enlargement (-)
Chest
Spider navi (+)
Heart:
Ictus palpable at ICS V+1 cm lateral lateral MCL S
LHM ictus RHM: SL D
S1, S2 single, murmur (-)
Lung:
Symmetric, SF D=S,
Percusion: S S
V V Rh - Wh - S S
V V
- - S S
V V
- - Abdomen
Ronded, distended, bowel sound (+) normal, liver span 4 cm,
traubes space timpani, shifting dullness (+)
Extremities
edema -/- , warm acral
-/Urine output
250 cc/12 hours

Laboratory Findings
LAB
VALUE
Hemoglobin
9.0 3.5
MCV
85.8
MCH
26.10

NORMAL
11,0-16,5 g/dl
80-96 f
26,5-33,5 pg

LAB
RBS
Ureum

VALUE
115
58.3

NORMAL
< 200 mg/dl
10-50 mg/dL

Leukocyte
Eo/Bas/Neu/
Limf/Mon
PCV
Trombocyte

11,080

5,360
1/0.4/71.1/18
.8/8.7
29.6

SGOT

177,000
104,000
72

SGPT

34

ECG

3.50010.000/L
0-4/0-1/5167/25-33/2-5
35-50%

Creatinine

0.82

0,7-1,5 mg/dL

Natrium

132

Kalium

5.48

150.000390.000/L
0-32 U/L

Chlorida

107

136-145
mmol/L
3,5-5,0
mmol/L
98-106
mmol/L

PPT
INR
APTT

12.7
1.09
31.4

0-32 U/L

Sinus rhythm with HR 118 bpm

Frontal Axis
: normal
Horizontal Axis
: normal
PR interval
: 0.12
QRS complex
: 0.08
QT interval
: 0.36
Conclusion: Sinus tachycardia with HR 118 bpm

Endoscopy (September 19th 2014)

Oesophageal varicess grade III
Portal hypertension gastropathy

CUE AND CLUE

PL

IDx

PDx

PTx

PMo and
PEdu

1. Shock condition
Male, 55 yo
Bloody vomiting, black-tarry
stool

1.1 Hypovolemic
shock due to
hematemesis
melena

At ER:
Insert NGT fasting GL 3x if
clear start with fluid diet 6 x 200
cc

Difficult to sleep

1.1.1

VE rupture

O2 10 lpm NRBM

Having liver disease since 5

months ago

1.1.2

PUB

I: IVFD NaCl 0.9% 20 cc/kg/hour

continue with 30 dpm

1.1.3

Portal
hypertensio
n
gastropathy

Consume spironolacton and

propranolol

II: bolus somatostatin 250 mg

continue with dri 250 mg/hour
III: bolus omeprazole 80 mg
continue with lansoprazole
8mg/hour

ER BP = 60/palp
Ward BP = 80/60 mmHg on NE
PR = 118 bpm, regular, strong
RR = 16 bpm

1.2 Cardiogenic
shock

Intravenous injection:
Ceftriaxone 1 x 1 gram
Metoclopramide 3 x 10 mg

Pale conjunctiva (+)

liver span 4 cm

Peroral:
Lactulose 3 x 30 cc

Hb: 9.0 3.5

Evaluation after 1 hour:

Subjective,
vital signs
(BP, RR,
PR, Tax),
urine
production
, NGT
production

PLT: 177,000 104,000

BP: 90/60 mmHg

PR: 109x/m
RR: 18x/m

Endoscopy:
Oesophageal varicess grade III
Portal
hypertension
gastropathy

Male, 55 yo
Bloody vomiting, black-tarry
stool

2. Anemia
normochrome
normocytair

2.1 Acute blood

loss
2.2 Chronic
disease

ER BP = 60/palp
Ward BP = 80/60 mmHg on NE
PR = 118 bpm, regular, strong
RR = 16 bpm
Pale conjunctiva (+)

Hb: 9.0 3.5

PLT: 177,000 104,000

Pro transfusion PRC 2 packs/ day

until Hb > 8 mg/dL

Subjective,
vital signs,
CBC post
transfusio
n

Male, 55 yo
Bloody vomiting, black-tarry
stool
Difficult to sleep
Constipation since 2 days ago
Having liver disease since 5
months ago
Consume spironolacton and
propranolol

ER BP = 60/palp
Ward BP = 80/60 mmHg on NE
PR = 118 bpm, regular, strong
RR = 16 bpm
Pale conjunctiva (+)
Spider navi (+)
liver span 4 cm, shifting
dullness (+)

3. Cirrhosis
hepatis on
treatment

3.1 post necrotic

hepatitis B

HbsAg
Anti HCV

3.2 post necrotic

hepatitis C

Bilirubin
T/D/I
albumin

Plan for spironolacton and

propranolol if the bleeding stop and
condition was stable

Monitor:
Subjective
Vital sign

Hb: 9.0 3.5

PLT: 177,000 104,000
PPT: 12.7
INR: 1.09
APTT: 31.4

Endoscopy:
Oesophageal varicess grade III
Portal
hypertension
gastropathy
Male, 55 yo
Bloody vomiting, black-tarry
stool
Difficult to sleep
Constipation since 2 days ago
Having liver disease since 5
months ago
Consume spironolacton and
propranolol

4. Hepatic
encephalopat
hy

4.1 due to
cirrhosis

NCT
EEG
Ammonia
blood level

BCAA 2 x 500 cc/24 hours

ER BP = 60/palp
Ward BP = 80/60 mmHg on NE
PR = 118 bpm, regular, strong
RR = 16 bpm
Pale conjunctiva (+)
liver span 4 cm

Hb: 9.0 3.5

PLT: 177,000 104,000
PPT: 12.7
INR: 1.09
APTT: 31.4

Endoscopy:
Oesophageal varicess grade III
Portal hypertension
gastropathy