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C3
A 31 year-old female was admitted to R.D.
Kandou Hospital at C3 ward on Sunday , 11th
December 2017
Habit history :
Alkoholism (-), Smoking (-)
Family History
None experienced the same illness
General anamnesis ( review of system )
General : abdominal enlargement
Skin :
Head and neck : -
Eye :-
Ear :-
Nose :-
Mouth and throat: -
Respiratory :
Chest :-
Heart :
Abdomen : Abdominal enlargement
Genitalia :-
Extremitas : Leg and foot swelling
Kidney :
Hematology :
Endocrine :
Musculosceletal :-
Physical Examination
GC: Moderate ill Sens : CM
C3:BP: 110/70mmHg, PR 80x/m, RR 18x/m, T 36,8C
ER :BP: 110/70mmHg , N 80x/m, RR 18x/m, T 36,8 C
BW 52 kg, BH 165 cm, BMI 19 kg/m2
Head : conj. anemic (+), scl. icteric(-),
Neck : JVP 5+0 cmH20, lymph nodes enlargement (-), thyroid (-)
Thorax :
Heart :
Insp : IC not visible
Palp : IC not palpable,
Perc : left border: ICS V midclavicullar line
right border: ICS IV parasternal line
Ausc : SI-II regular, murmur (-), gallop (-)
Physical examination
Lung : Insp : Symmetric
Palp : stem fremitus R = L
Perc : sonor
Ausc : vesicular, ronchi -/-, wheezing -/-
Abd :
Insp : Soepel , symmetric, ascites(+)
Palp : Tender, pain (-)
Liver palpable 10 cm b.a.c 5cm below proc.xiphoid ,
lump (-), spleen not palpable
Solid and immobile mass on the adnexa
Perc : Shifting dullness (+)
Ausc : Bowel sound (+) normal
Waist : Pain on CVA exam (-/-)
Extr : inferior: warm, edema (+/+)
RT : Feses +, Blood (-), Mass (-)
Lab Result
11/12/2017 8.30 WITA
Leucocyte 18300 Gamma GT 488
RBC 3.27
Hb 7 Bil.Total 1.74
Ht 37.3%
Platelet 831.000 Bil.Direct 0.82
MCH 21.4
MCHC 31 HCV rapid (-)
MCV 69.1 HbsAg (-)
SGOT 43
SGPT 25
RBS 100
Cl 85.9
K 3.87
Na 121
Ureum 11
Creatinine 0.5
Lab Result
11/12/2017 21.30 WITA
Leucocyte 17300 PT : 17,3/13,2
RBC 3.27 APTT : 42,1/32,9
Hb 7.2
Ht 37.3%
Platelet 818.000
MCH 21.4
MCHC 31
MCV 69.1
Albumin 2.49
Serum Iron 11
TIBC 140
Ureum 10
Creatinine 0.6
Calcium 8.84
Phosphor 3.6
USG abdomen 11/12/2017
Problem List
No CM : 519497 Age : 31 y.o
1. Main complain:
Abdominal enlargement
2. Anamnesis:
Abdominal enlargement
Fatigue & general weakness
3. Physical examination:
GC: Moderate ill Sens : CM
C3:BP: 110/70mmHg, PR 80x/m, RR 18x/m, T 36,8C
Head : conj. anemic (+), scl. icteric(-),
Abd :
Insp : Soepel , symmetric, ascites(+)
Palp : Tender, pain (-)
Liver palpable 10 cm b.a.c 5cm below proc.xiphoid ,
lump (-), spleen not palpable
Solid and immobile mass on the adnexa
Perc : Shifting dullness (+)
Extr : inferior: warm, edema (+/+)
Roentgen
Roentgen INTERPRETATION
Roentgen Componen Interpretation
Identity Same
KV Normal
Symmetric Symmetric
Trachea Middle
Diaphragma Normal
Sinus Costophrenicus Sharp
Sinus Cardiophrenicus Sharp
Bone Intact
COR CTR 9.8/21= 46%
Pulmo Parenchym Patch (-)
CONCLUSION : Normal
ECG : Normal sinus rhythm, 75x/min
ECG INTERPRETATION
ECG components Interpretation Value
Rhythm Sinus Sinus Rhythm
Speed / HR (times/mnt) 75x/min 1500/R-R
Axis Normal Normal / RAD / LAD
Morphology P wave 0,10 sec Lead II : Duration 0.10, Height 2.5
PR Interval 0,20 sec 0,12 0,20
QRS complex duration 0,08 sec 0,05 0,11``
ST segmen Normal Normal / Elevated / Depressed
T wave Normal Normal / abnormal
QT Interval 0,40 sec cQT = QT interval / vR-R Interval
U wave Absent Appear / not appear
CONCLUSION : Normal sinus rhythm, HR 75x/m
Karnofsky scale 80
1+2+1+3+1
CTP Class B (1 year survival 45%, 2 year survival
35%)
APRI SCORE 0.16
Thrombocyte 831.000
SGOT 43
No Problem List Plan Dx Plan Tx Non pharm tx Plan Monitoring
1 Abdominal
enlargement.
Uric Acid o
Treat primary Educate the Observation for
disease family about vital signs, body
C3:BP: 110/70mmHg, CT-Scan with the condition of weight, waist
PR 80x/m, RR 18x/m, contrast the patient and circumference,
T 36,8C plans ahead. decrease of
Head : conj. anemic Tumour Marker consciousness,
(+), scl. icteric(-),
CEA,AFP, Ca 125 bleeding
Abd :
Insp : Soepel , B-HCG
symmetric,ascites(+)
Palp: Tender, pain (-) Liver BIopsy
Liver palpable 10
cm b.a.c 5cm below
proc.xiphoid , PET SCAN
lump (-),
Solid and immobile
mass on the adnexa
Perc: Shifting
dullness (+)
sound (+) normal
USG abdomen :
Multiple nodule on liver
Ascites
Mass on the
uterus/ovarium
Multiple nodular
Hepar ec
Metatase dd
hepatome dd
Hepatic
Cholangio
Carcinoma
No Problem List Plan Dx Plan Tx Non pharm tx Plan Monitoring
2 Fatigue
Eye : Sclera Icteric (+)
Blood Smear o
Treat Primary Educate the Observation for
BMP if needed disease family about the vital signs
Hb 7.2 condition of the
MCV 69.5
MCH 21.8
Sulfas Ferrous patient and plans
MCHC 31.3 tab. 250mg/12 hr ahead.
SI 11
TIBC 140 Transfusion PRC II
Anaemia bag
Hipochromic
Microcyter ec
Iron Deficiency dd
Chronic Disease
4 Laboratory:
Thrombist : 831.000
Blood Smear o
Treat Primary Educate the Observation for
BMP if needed Disease family about the vital signs
PT 17.7/13.2 condition of the
APTT 42.1/32.9
patient and plans
ahead.
Thrombositosis
Reactive