FOLLOW UP Panjang Ki2

7/29/2019 FOLLOW UP Panjang Ki2

1/8

FOLLOW UP

October, 10th 2009

S Bulging of abdomen

O

General condition

Conciousness : compos mentis

Blood preassure : 140/80 mmHg

Pulse rate : 80x/minute

Respiration rate : 20x/minute

Temperature : 36,5C

Spesific condition

Pale of conjunctiva palpebra (+), icteric sclera (+), exopthalmus (-)Jugular venous pressure (5-2) cmH2O, lymph nodes enlargement (-), thyroid gland enlargement (-).

Cor

Inspection : ictus cordis was not seenPalpation : ictus cordis was not palpable

Percussion : upper heart margin at 2nd intercostal space, right margin at linea sternalis dextra , left marginat linea midclavicularis sinistra

Auscultation : HR 80 x/menit, murmur (-), gallop (-)

Pulmo

Inspection : static: both hemithoraxs were symmetric. dynamic: same movement, no retraction

Palpation : stemfremitus in both hemithoraxs were equalPercussion : sonorous in both lungs, border of pulmo-liver at ICS V

Auscultation : vesiculair (+) normal, rales (-), wheezing (-)

Abdomen

Inspection : dome-shaped, collateral vein (+)Palpation : tender, borderline of pulmo-liver at ICS V, pressure pain (-), liver and spleen couldnt be

examined.Percussion : stony-dull, fluid wave test (+)

Auscultation : normal bowel sound

Extremities : eritema palmar +/+

pretibial edema +/+

A

Decompensated hepatic cirrhosis + anemia ec chronic disease + hypertension stage II

DD/ Decompensated hepatic cirrhosis + anemia ec Fe deficiency + hypertension stage II

P

Bed rest

Liver diet III

IVFD RL gtt X/m (micro)

Furosemid 1x40mg

Spironolacton 2x100mg

Vit Bcomplex 3x1tab

Curcuma 3x1tab

Nifedipine 4x1

Clonidine 3x0,25

Ceftriaxon 1x1 gram

October, 12th 2009

S Bulging of abdomen, coughing

O

General condition


Blood preassure : 140/70 mmHg Pulse rate : 84x/minute


9


2/8

Temperature : 36,6C

Spesific condition

Pale of conjunctiva palpebra (+), icteric sclera (+), Jugular venous pressure (5-2) cmH 2O

Cor: HR 84 x/menit, murmur (-), gallop (-)

Pulmo: vesiculair (+) normal, rales (-), wheezing (-)

Abdomen

Inspection : dome-shaped, collateral vein (+)

Palpation : tender, borderline of pulmo-liver at ICS V, pressure pain (-), liver and spleen couldnt beexamined

Percussion : stony-dull, fluid wave test (+)Auscultation : normal bowel sound

Extremities : eritema palmar +/+ pretibial edema +/+

A

Decompensated hepatic cirrhosis + anemia ec chronic disease + hypertension stage II

DD/ Decompensated hepatic cirrhosis + anemia ec Fe deficiency + hypertension stage II

P

Bed rest

Liver diet III


Furosemid 1x40mg


Vit Bcomplex 3x1tab

Curcuma 3x1tab

Clonidine 3x0,25

Ceftriaxon 1x1 gram

October, 13th 2009

S Dyspnea, no defecation for the last4 days

O

General condition





Temperature : 36,1C

Spesific condition




Abdomen


Palpation : tender, borderline of pulmo-liver at ICS V, pressure pain (-), liver and spleen couldnt beexamined.



A

Decompensated hepatic cirrhosis + anemia ec chronic disease + hypertension stage IIDD/ Decompensated hepatic cirrhosis + anemia ec Fe deficiency + hypertension stage II

P

Bed rest

O2 3-5 l/minute

10


3/8

Liver diet III


Furosemid 1x40mg


Vit Bcomplex 3x1tab

Curcuma 3x1tab

Clonidine 3x1 Ceftriaxon 1x1 gram

Dulcolax sup ( night )

October, 14th 2009

S Dyspnea, BAB (-)

O

General condition





Temperature : 36,4C

Spesific condition

Pale of conjunctiva palpebra (+), icteric sclera (+). Jugular venous pressure (5-2) cmH 2O

Cor: HR 82x/menit, murmur (-), gallop (-)


Abdomen





A

Decompensated hepatic cirrhosis + anemia ec chronic disease + hypertension stage IIDD/ Decompensated hepatic cirrhosis + anemia ec Fe deficiency + hypertension stage II

P

Bed rest

O2 3-5 l/minute

Liver diet III


Furosemid 1x40mg Spironolacton 2x100mg

Vit Bcomplex 3x1tab

Curcuma 3x1tab

Clonidine 3x1

Ceftriaxon 1x1 gram

Dulcolax sup ( night )

Laxadine 3x1c

Planning :

Check haematology and clinical chemistryAbdominal USG

October, 15st 2009

S -

11


4/8

O

General condition





Temperature : 36C

Spesific condition


Cor : HR 82 x/menit, murmur (-), gallop (-)


Abdomen


Palpation : tender, borderline of pulmo-liver at ICS V, pressure pain (-), liver/ spleen couldnt beexamined.

Percussion : stony-dull, fluid wave test (+)



Laboratory finding:Haematology

Haemoglobin : 7,2 g/dl (14-18, 12-16 g/dl)Haematocrite : 21% (40-48 vol%)

Erythrocyte : 2.420.000/mm3 (2.500.000-4.500.000/mm 3)MCH : 29 picogram (27-31 picogram)

MCV : 78 gram (82-92 gram)MCHC : 30% (32-36%)

Leucocyte : 4.800/mm3 (5000-10.000/mm3)ESR : 88 mm/h (


5/8

Liver diet III

IVFD D5% gtt X/m (micro)

Furosemid 1x40mg


Vit Bcomplex 3x1tab

Curcuma 3x1tab

Clonidine 3x1 Ceftriaxon 1x1 gram

Planning :Human albumin 20% 50cc / day

diagnostic Paracentesis ascites liquid

October, 16th 2009

S Headache

O

General condition




Temperature : 36,5C

Spesific condition




Abdomen





parasintesis ascites liquid 1800 cc

A Decompensated hepatic cirrhosis + anemia ec chronic disease + hypertension stage II

P

Bed rest

Liver diet III


Furosemid 1x40mg


Vit Bcomplex 3x1tab

Curcuma 3x1tab

Clonidine 3x1

Ceftriaxon 1x1 gram

Albumin 20% 50 cc day 1

October, 17th 2009

S -

13


6/8

O

General condition





Temperature : 36,6C

Spesific condition

Pale of conjunctiva palpebra (+), icteric sclera (+), Jugular venous pressure (5-2)



Abdomen



Percussion : stony-dull, fluid wave test (+)



ADecompensated hepatic cirrhosis + anemia ec chronic disease + hypertension stage II

P

Bed rest

Liver diet III



Vit Bcomplex 3x1tab

Curcuma 3x1tab

Clonidine 3x1

Albumin 20% 50 cc day 2

October, 19th 2009

S Dyspnea, coughing

O

General condition





Temperature : 36,5C

Spesific condition




Abdomen


examined.



14


7/8


P

Bed rest

O2 3-5 l/minute

Liver diet III


Spironolacton 2x100mg Vit Bcomplex 3x1tab

Curcuma 3x1tab

Clonodine 3x1

Nifedipine 4x1

October, 20th 2009

S Epigastic pain, dyspnea, coughing

O

General condition





Temperature : 37,1C

Spesific condition




Abdomen


Palpation : tender, borderline of pulmo-liver at ICS V, pressure pain (-), liver and spleen couldnt beexamined.Percussion : stony-dull, fluid wave test (+)




P

Bed rest

O2 3-5 l/minute

Liver diet III


Furosemide 2x40 mg


Vit Bcomplex 3x1tab

Curcuma 3x1tab

Clonidine 3x0,25

October, 21st 2009

S dyspnea

O

General condition




15


8/8

Temperature : 37,1C

Spesific condition




Abdomen






P

Bed rest

O2 3-5 l/minute

Liver diet III


Furosemide 2x40 mg


Vit Bcomplex 3x1tab

Ceftriaxon 1x1 gram

Curcuma 3x1tab

Clonidine 3x0,25

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FOLLOW UP Panjang Ki2