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    No Identity Admission To ER Diagnosis Treatment

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    monyet65
    1. Mr. Ricardo, age 42, presented to the emergency room with abdominal pain and was diagnosed with multiple lobulated liver abscesses and anemia. 2. He received intravenous fluids, antibiotics, and a PPI in the emergency room and was then admitted for percutaneous abscess drainage and further treatment. 3. His laboratory tests showed worsening anemia and liver function abnormalities consistent with liver abscesses.

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    No Identity Admission To ER Diagnosis Treatment

    Uploaded by

    monyet65
    30 views22 pages
    1. Mr. Ricardo, age 42, presented to the emergency room with abdominal pain and was diagnosed with multiple lobulated liver abscesses and anemia. 2. He received intravenous fluids, antibiotics, and a PPI in the emergency room and was then admitted for percutaneous abscess drainage and further treatment. 3. His laboratory tests showed worsening anemia and liver function abnormalities consistent with liver abscesses.

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    1. Mr. Ricardo, age 42, presented to the emergency room with abdominal pain and was diagnosed with multiple lobulated liver abscesses and anemia. 2. He received intravenous fluids, antibiotics, and a PPI in the emergency room and was then admitted for percutaneous abscess drainage and further treatment. 3. His laboratory tests showed worsening anemia and liver function abnormalities consistent with liver abscesses.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    30 views22 pages

    No Identity Admission To ER Diagnosis Treatment

    Uploaded by

    monyet65
    1. Mr. Ricardo, age 42, presented to the emergency room with abdominal pain and was diagnosed with multiple lobulated liver abscesses and anemia. 2. He received intravenous fluids, antibiotics, and a PPI in the emergency room and was then admitted for percutaneous abscess drainage and further treatment. 3. His laboratory tests showed worsening anemia and liver function abnormalities consistent with liver abscesses.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
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    Patient List

    No Identity Admission to ER Diagnosis Treatment

    2. Mr. Ricardo / 42. Admitted in Abcess Hepar + Treatment from ER:


    Y.O / 1.45.86.72 / April 18th 11.30 Anemia (9.7) • IVFD NACL 0.9% 10 tpm
    PM • Inj. Omeprazole 1x40mg
    • Inj. Cefobactam 3x1 gr
    • Inj Metronidazole
    3x500mg
    • Complete Blood Count
    Consult to Digestive:
    • Hospitallized
    Mr. Ricardo / 42. Y.O / 1.45.86.72 /
    Admitted in April 18th 11.30 PM

    Chief Complained : abdominal pain


    History :
    He came with complained of pain at the abdomen since 3 weeks ago. At the beginning, pain came
    at the right upper abdomen and felt intermittently with stabbing sensation accompanied by fever. The
    fever felt intermittent. He also complained yellowing of his eyes and skin. He complained anorexia
    and loss of weight.
    He had history of being alcoholic since 10 years ago.
    There was no history of abdominal trauma, hepatitis, surgery, Dark stool before. His house didn’t
    located near a river and his drinking source didn’t bring from the river.

    History of Past Illness: Hepatitis (-), HT (-), DM (-)


    History of Family Illness: HT (-), DM (-), tumor (-)
    Vital Sign
    • GCS : E4 V5 M6
    • BP : 120/80
    • HR : 85x/ m
    • RR :22x/ m
    •T : 37.8o C
    • CRT : <3 second
    • SpO2 : 99% without O2 supplementary
    Physical Examination
    •Eye: pale conjungtiva (+/+), sclera icteric (+/+), pupil equal 3 mm|3 mm.
    Head/Neck •Neck: Lymphn Node Enlargement -/-

    • I : symmetric respiratory movement, retraction (-)


    • P : symmetric VF
    Chest • P : sonor at all lung fields
    • A : symmetric VBS, no ronchi, no wheezing

    • I : distention (+), mass (+), darm countur (-), darm steifung (-), scar (-)
    • A : bowel sound (+) 4-5x/minute, metalic sound (-)
    • P : hypertympanic (+)
    Abdomen • P : Tenderness (+) at right upper quadran, defands muscular (-), liver (+) palpable
    20cm x 10cm x 2cm, Regular border, soft, mobile , spleen not palpable, skin turgor
    decreased

    Extremities • warm (+), edema pitting pretibial (+/+),


    Digital Rectal Examination
    I : mass (-), Haemorrhoid (-), Fistule (-)
    P:
    - Spincter ani tone : normal limit
    - Mucosa slippery
    - Ampulla was not collapse
    - Mass (-) rectum hard to evaluate because fecal material
    - Fecal material hard consistency  brown greenish colour, blood (-)
    - Handschoen: Faeces (-), Blood (-)
    Clinical Pictures
    Clinical Pictures
    Laboratory Finding in Suaka Insan Hospital on April
    17th 2020
    Examination Result Normal Value
    Hemoglobin 9.2 14,00-16,00 g/dl
    Leukosit 18.7 4,0-10,5 thousand/ul
    Eritrosit 3.13 3,90-5,50 million/ul
    Hematokrit 27.1 37,00-47,00 vol%
    Trombosit 160 150-450 thousand/ul
    RDW-CV --- 11,5-14,7 %
    MCV 86.7 81,0-99,0 fl
    MCH 29.4 27-31pg
    MCHC 33.9 33.0-37.0
    Uric Acid 5.3 3.6-7.0
    Total Cholesterol 53 <200
    HDL 10 >35
    LDL 27 <150
    Trigliseride 78 <150
    Laboratory Finding in Suaka insan Hospital on April 17th
    2020 Examination Result Normal Value
    Alkaline Phospatase - 40-150
    RBG - 108
    Albumin 2.2 3.5 – 5.2
    Biltot 9.69 0.2 -1.2
    Bilirubin Direct 8.09 0.0 – 0.2
    SGOT 257 0-46 U/l
    SGPT 75 0-45 U/l
    Ureum 82 10-50 mg/dl
    Creatinin 0.4 0,7-1,4 mg/dl
    Natrium 128 135-146 mmol/l
    Kalium 3.7 3,4-5,4 mmol/l
    Chlorida 96 95-100 mmol/l
    Laboratory Finding in Siaga Hospital on April 18th
    2020
    Examination Result Normal Value
    Hemoglobin 8.9 14,00-16,00 g/dl
    Leukosit 16.5 4,0-10,5 thousand/ul
    Eritrosit 2.95 3,90-5,50 million/ul
    Hematokrit 27.2 37,00-47,00 vol%
    Trombosit 198 150-450 thousand/ul
    RDW-CV 17.5 11,5-14,7 %
    MCV 92.2 81,0-99,0 fl
    MCH 30.2 27-31pg
    MCHC 32.7 33.0-37.0
    PT 9.1 7.9-10.3
    INR 0.98
    APTT 26.7 20-30.3
    Laboratory Finding in Siaga Hospital on April 18th 2020
    Examination Result Normal Value
    Alkaline Phospatase --- 40-150
    RBG --- 108
    Albumin --- 3.5 – 5.2
    Biltot 6.08 0.2 -1.2
    Bilirubin Direct 4.97 0.0 – 0.2
    SGOT 63 0-46 U/l
    SGPT 95 0-45 U/l
    Ureum 30 10-50 mg/dl
    Creatinin 0.9 0,7-1,4 mg/dl
    Natrium --- 135-146 mmol/l
    Kalium --- 3,4-5,4 mmol/l
    Chlorida --- 95-100 mmol/l
    Laboratory Finding in Ulin Hospital on April 18th
    2020
    Examination Result Normal Value
    Hemoglobin 9.2 12,00-16,00 g/dl
    Leukosit 17.0 4,0-10,5 thousand/ul
    Eritrosit 2.99 3,90-5,50 million/ul
    Hematokrit 27.3 37,00-47,00 vol%
    Trombosit 219 150-450 thousand/ul
    RDW-CV 18.6 11,5-14,7 %
    MCV 91.3 81,0-99,0 fl
    MCH 30.8 27-31pg
    MCHC 33.7 33.0-37.0
    Gran% 90.2 50-70%
    Limfosit% 6.1 25-40%
    Gran# 15.4 2.50-7.00 thousand/ul
    Limfosit# 1.0 1.25-4.0 thousand/ul
    Laboratory Finding in Ulin Hospital on April 18th 2020
    Examination Result Normal Value
    Alkaline Phospatase 340 40-150
    RBG 108 108
    Albumin 2.7 3.5 – 5.2
    Biltot 10.75 0.2 -1.2
    Bilirubin Direct 9.90 0.0 – 0.2
    SGOT 254 0-46 U/l
    SGPT 88 0-45 U/l
    Ureum 77 10-50 mg/dl
    Creatinin 1.32 0,7-1,4 mg/dl
    Natrium 131 135-146 mmol/l
    Kalium 3.9 3,4-5,4 mmol/l
    Chlorida 108 95-100 mmol/l
    Covid Screening , April 18th 2020, Siaga
    Hospital
    USG Abdomen, April 11th 2020, Suaka Insan Hospital
    Thorax Xray PA, April 11th 2020, Suaka Insan Hospital
    CT Scan Thorax Non Contrast, April 13th 2020, Suaka Insan Hospital
    CT Scan Thorax Non Contrast, April 13th 2020, Suaka Insan Hospital
    CT Scan Abdominal Non Contrast, April 16th 2020, Suaka Insan Hospital
    CT Scan Abdominal Non Contrast, April 16th 2020, Suaka Insan Hospital
    Diagnosis
    Multi lobulated liver Abcess + Anemia (9.7)
    Management
    Treatment from ER: Consult to Digestive:
    • IVFD NACL 0.9% 10 tpm • Hospitallized
    • Percutaneus abscess
    • Inj. Ceftriaxon 2x1 gr drainage
    • Inj Metronidazole 3x500mg
    • Inj. Omeprazole 1x40mg
    • Complete Blood Count

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