General ward report 25th november 2015

1. Resident on Duty: dr. Anshari & dr. Anggar
Coass: Dondy Juliansyah

2.  Mr. L: Acute on Chronic Hepatitis B DD/
Obstructive Icterus
 Mr. R: Dog Bites
 Mr. N: Chronic Diarrhea
 Mrs. D: Melena +Geriatric Problems

3.  Name: L
 Sex: Male
 Age: 60 year old
 Occupation: Retired
 Religion: Moslem

4.  Based on autoanamnesis
 Chief Complaint:Yellow discoloration of the
skin for 12 days

5.  Patient was referred to RSPAD Gatot Soebroto from Lampung
with history of yellow discoloration of the skin for 12 days. He also
complains of nausea and vomiting twice a day, containing food,
green color (-), blood (-). He mentions that his stool was putty-
coloured and his urine turned dark (tea coloured). At this time, the
patient was able to eat and drink.
 2 days before admission, his yellow skin got worse. He also reports
that he had intermittent abdominal pain which was located in the
right upper quadrant of the abdomen. He describes the pain as
“blunt pain”, withVAS 2 – 3.The pain was alleviated with rest, but
not associated with food.There was no cold sweat and fever.
 He also reports that he had swollen belly since the previous day.
He couldn’t defecate for 2 days but he still passed gas. He also
mentions that he had swollen feet. He denies shortness of breath,
cough, palpitation, DOE, PND, ortopnea, chest pain, black stool,
and vomiting blood. His appetite was decreased, but he could
drink. He had experienced a weight loss of about 5 – 10 kgs in 12
days.

6.  He had testicular surgery on May 2015 and
the histopathology showedTB. He took
medications for 5 months, and quit after his
skin turned yellow. He was hospitalized, and
his labs test showed HepB and the ultrasound
revealed obstruction of his bile.
 No history of jaundice, diabetes,
hypertension, renal disease, and blood
transfusion.

7.  No history of the same complaint.
 No history of diabetes, hypertension, and
jaundice.

8.  Smoking (+) 2 packs a day for 20 years.
 No alcohol and drug use.

9.  General: moderately ill, compos mentis
 Vital Signs:
 BP: 127 / 60 mmHg
 HR: 60 beats/minute
 T: 37,8 C
 RR: 20 breaths/minute
 Weight/Height: 85 kgs/170cms
 BMI: 29.4 (obese I)

10.  Head: Normocephal
 Eyes: Pale conjunctiva (-/-), Icteric sclera (+/+)
 ENT:TonsilsT1 –T1, hyperemic pharynx (-),
discharge (-)
 Neck: JVP 5 – 1 cmH2O, Lymph nodes not
palpable

11.  Chest: Normochest, Gynecomastia (-), Spider Naevi (-
), Axillar hair (+)
 Cor:
 I: Ictus Cordis not seen
 P: Ictus Cordis not palpable
 P: Enlargment of heart to the left
 A: S I – II normal, Regular, Gallop (-), Murmurs (-)
 Pulmo:
 I: Symmetrical movement
 P: Symmetrical tactile fremitus
 P: Sonor percussion sound
 A:VBS (+/+), Crackles (-/-), Wheezes (-/-)

12.  Abdomen:
 I: Icteric, distended, caput medusae (-)
 A: Normal Bowel Sounds
 P:Tympanic percussion sound
 P: Palpable Liver 3 fingers BAC, nodule (-),
smooth, blunt edge, tenderness (+), Murphy Sign
(+), Spleen not palpable, shifting dullness (+), fluid
wave test (+)
 Extremities: Icteric, Oedem (-),Warm, CRT <2
sec

13.  Blood count:
 Hb: 12,1 g/dL
 Ht: 34%
 WBC: 23.470 /mm3
 Diff Count: 0/0/3/75/13/9
 Platelet: 822.000 /mm3
 MCV/MCH/MCHC: 61/22/36
 RDW: 27.90
 PT: 38.4/11.1 sec
 APTT: 112.8/33.6 sec
 Total Bilirubin: 28.10
 OT/PT: 111/105 U/L
 Total Protein/Alb/Glb:
6,1/2,3/3,8 mg/dL
 Ur/Cr: 44/1,1 mg/dL
 Uric Acid: 3,7 mg/dL
 Na/K/Cl: 130/5,2/93 mMol/L
 HbsAg/HCV: Reactive / -
 Current Blood Sugar: ?

14.  Male, 60 year old with yellow discolorization of the body for 12
days, nausea (+), vomiting (+), putty-colored stool (+), tea-colored
urine (+), intermittent blunt paint on RUQ of Abdomen,VAS 2 – 3,
alleviated with rest, not associated by food, he got swollen belly
since prev day, couldn’t defecate for 2 days, farted (+), swollen
feet (+). Loss of appetite (+), still able to drink (+), He experienced
a weight loss of about 5 – 10 kgs in 12 days. He had testicular
surgery on May 2015 and the histopathology showedTB. He took
medications for 5 months, and quitted after his skin turned yellow.
He was hospitalized, and his labs test showed HepB and the
ultrasound revealed obstruction of his bile.
 PE:T: 37,8 C; BMI: Obese, Icteric Sclera (+), heart enlargement.
Abd: Icteric, distended,Tympani (+), Hepar 3 fingers BAC, blunt
edge, nodule (-), tenderness (+), Murphy sign (+), shifting dullness
(+), Fluid wave test (+).
 Laboratory: Microcytic Hypochrom Anemia, leukocytosis,
trombocytosis, Prolonged PT/APTT, Hyperbillirubinemy, elevated
OT/PT, Hypoalbumin, HBsAg (+).

15.  Jaundice
 Hepatic: Acute on Chronic Hepatitis B, DIH
 Post Hepatic: Cholelithiasis
 Hypoalbuminemia

16.  Jaundice
 Based onYellow discolorization of the body for 12 days,
nausea, vomiting, blunt pain on RUQ abdomen, putty-
colored stool, tea-colored pee, History of HepB, History of
gall stone. History ofTB medication for 5 months.
 PE: Icteric, Abd: Distended,Tenderness RUQ (+), Hepar 3
fingers BAC, blunt edge, nodule (-), tenderness (+),
murphy sign (+)
 PP: Leukocytosis, prolonged PT/APTT,
Hyperbillirubinemy, elevated OT/PT, Hypoalbumin, HBsAg
(+)
 Dx: Icterus Hepatic: Acute on Chronic Hep B, DIH; Post
Hepatic: Obstructive jaundice Susp Cholelithiasis

17.  Diagnostic Plan: USG, Direct/Indirect Billirubin,
Lipid Profile, Stool Analysis
 Theurapetic Plan: NaCl 0,9 % 500 ml q12h,
Propanolol 1 x 10 mg P.O, Hepapro 3 x 1 tab,
Ranitidin 2 x 50 mg IV, Urdafalc 2 x 1 tab

19.  Hypoalbuminemia
 Based on feet swelling and stomach swelling
 PE: shifting dullness (+), Pretibial oedema (+),
Albumin 2,3 mg/dL
 Dx: Hypoalbuminemia Susp. Chronic Liver Disease
 Diagnostic plan: Serial Albumin, Urinalysis
 Theurapetic plan: Spironolacton 2 x 100 mg P.O,
Furosemide 1 x 40 mg P.O
 Education plan: high protein diet.

20.  Quo ad vitam: dubia ad bonam
 Quo ad Sanationam: dubia ad bonam
 Quo ad Functionam: dubia