case

1. Afriani/Female/24 yo/FW 15
Chief Complaint:
• Weak and tired since 10 days ago
Present Illness History
• Weak and tired increased since 10 days ago
• The patient started to feel weak and tired since a month ago
• Looked pale
• Pain in the upper abdomen since a week ago, the patient started to feel
pain since 5 months ago and sometimes feel heartburn
• Nausea and vomit sometimes
• Swollen on both legs since 10 days ago
• No fever
• No shortness of breath or cough
• Patient was referred from M Natsir Hosp with susp Liver Cirrhosis for
further diagnosis and therapy
• Had USG Abdomen with the result Mild Hepatomegaly cb susp Hepatitis
dd Liver Cirrhosis, Ascites, and Cystitis
• Had blood transfusion for 3 bags
• The patient is currently having first pregnant with last menstruated in
January 16th 2023

2. • Hypertension (-)
• History of DM (-)
Past illness history
• The patient doesn’t consume any drugs
drug history

3. VII
• General Appearance : Moderate
• Consciousness level: CMC
• BP : 98/70 mmHg
• HR : 98 x/minute
• RR : 19 x/minute
• T : 36.5º C
• SpO2 : 96 %
Physical Examination

4. VII
• Eye
–conjunctiva anemic (+/+), icteric sclera (-/-), isochoric pupil
• Neck
–JVP 5-2 cmH20,
• Lung:
–Inspection: statically & dynamically symmetric, no cicatrix found
–Palpation: fremitus tactile right = left normal ,crepitation -
–Percussion: sonor both of lung
–Auscultation: vesicular +/+, Rh -/- Wh -/-
• Cor:
–Inspection: ictus cordis is not seen
–Palpation: ictus is palpated ric V lmcs ,1 finger medial
–Percussion:
• Left border: 1 finger medial LMCS ICS v
• Right border: linea sternalis dextra iv
• Upper border: ICS II linea parasternalis sinistra
–Auscultation: s1-2,regular, murmur (-), gallop-

5. VII
• Abdomen:
–Inspection: enlargement +, collateral vein -, caput medusae -
–Auscultation: bowel sound (+) N
–Palpation:, Epigastric Pain + hypochondriaca dextra +, liver and
Speen are not palpable, Fundus Uteri 2 fingers upper umbilicus
–Percussion: tympani
• Extremities:
Oedema +/+, CRT< 2 sec, left leg have a reddnes , warm and pain

6. VII
Laboratory
Items Value
Hb 9.6 gr/dl
Ht 30%
Leukosit 10.760/mm3
Platelet 220.000/mm3
Alb/glo 1.9/2.9
MCV/MCH/MCHC 77/25/32
Ur/cr 2/0.2
SGOT/PT 16/8
BT/BD/BI 1.2/1/0.2
GDS 92
Na/K/Cl 139/3.6/110
HbsAg/Anti HCV/ Anti HIV NR/NR/NR

7. VII
ECG

8. Problems
- Ascites
- Oedem
- Hypoalbuminemia
- Susp Liver Cirrhosis in Pregnancy

9. Working Diagnosis
• Susp Liver Cirrhosis
• Hypoalbuminemia cb Low Intake
• Ascites cb Hypoalbuminemia
• Mild Anemia Normocytic Normochrome cb Chronic Disease
• Gravid 25-26 weeks

10. Therapy
• Rest/ Regular Diet
• IVFD: NaCl 0.9% /8 h
• Inj Ranitidine 2x1 amp
• Vit B6 1x1 tab
• Paracetamol 3x500mg
• Inj Dexamethasone 2x2amp
• Albumin Transfusion 25% continued with 20%

11. Plan
- Abdomen Ultrasound
- Fetomaternal Ultrasound
- Check fetal heart rate