MORNING REPORT

C1 ward
Mar, 27th 2024
 PATIENT IDENTITY

• Name : MP
• Age : 69 years old
• Sex : Female
• Education : Senior High School
A 69 year-old woman was admitted to R.D.
Kandou Hospital at C1 ward on

Mar, 27th 2024

Chief complaint: weakness

 PRESENT MEDICAL HISTORY
• Patient admitted to Prof Dr. R. D. Kandou Hospital due to chief complaint
of weakness.
• The patient reported experiencing weakness for the past 2 months,
accompanied by a decreased appetite.
• Weakness is also accompanied by nausea and vomiting. There is no
history of vomiting blood or vomiting greenish or blackish material.
• The patient also mentioned that their skin has started turning yellow 2
months ago.
• The last defecation was described as pale earlier this morning. The
patient reported dark tea-colored urine with a volume of about 1000-
1200 cc per day.
 PAST MEDICAL HISTORY
• The patient has a history of recurrent abdominal pain for the
past 6 months and underwent ERCP procedure on March 14,
2024. The patient's family stated that the results of the ERCP
have been consulted with a surgeon, and it was explained that
there is a tumor that has spread to the liver area.
• The patient has a history of hypertension and is being treated
with amlodipine 5 mg.
• There is no history of diabetes mellitus or gout.
 FAMILY HISTORY
• None experienced the same illness
 Physical Examination
• GC: Severely ill . Sens : CM
• Vital sign : BP: 111/68 mmHg; PR 83x/m, regular; RR 20
x/m, T 36.9oC, SpO2 96% room air, BW:53kg, H: 150cm
• Head : conj. Anemic (+), scl. Icteric(+)
• Neck : JVP distended (-) , lymph nodes enlargement (-)
• Thorax :
• Heart :
– Insp : IC not visible
– Palp : IC not palpable
– Perc : left border: ICS V midclavicular line
right border: ICS IV right parasternalis line
– Ausc : SI-II regular, murmur (-), gallop (-)
 PHYSICAL EXAMINATION
• Lung :
Insp : Symmetric
Palp : Stem fremitus R = L
Perc : Sonor
Ausc : Vesicular +/+, ronchi -/-, wheezing -/-
• Abdomen
Insp : Flat
Ausc : Normal bowel sound
Palp : Tender, No liver & spleen enlargement, Epigastric pain
(+)
Perc : Tympanic, shifting dullness (-)
• Extr : Warm, CRT <2 secs, edema -/-, icteric skin (+)
CHEST RADIOGRAPH
 RONTGEN INTERPRETATION
Rontgen components Interpretation
Identity, Name, Diagnosis Same
Side Marker (right/left) Correct
Film Type Anteroposterior (AP)
(AP/PA/Lateral/Erect)
Film Quality:
• Adequate Inspiration? Adequate
• Thoracal vertebrae? Adequate
• Clavicula and Sternum Symetric
symetric in middle
Tube/Cable No
Cor + CTR Aorta elongation and calcification
Pulmo (Trachea position, Normal
bronchi, hilar, vascular
pattern, infiltrate, cavity,
fibrosis, nodul, Pleural
thickening
 RONTGEN INTERPRETATION
Rontgen components Interpretation
Soft tissue and Bone Intact
• Neck, supraclavicula,
axilla, chest, mammae,
upper abdomen, gastric
gas, shoulder joint,
scapula, clavicula,
vertebrae, costae, and
sternum
Diaphragma Normal
Mediastinum (Shape, Normal
diapraghm height, free air,
tenting, elevation,
Flattening)
Sinus Costovertebrae Normal
Sinus Cardiophrenicus Normal
Conclusion: Aorta elongation and calcification
ECG
 ECG INTERPRETATION
ECG components Interpretation Value
Rhythm Sinus Sinus Rhythm
Speed / HR (times/mnt) 76 bpm 300/R-R’
Axis Normal Normal
Morphology P wave Normal Lead II : Duration ≤0.10”, Height ≤2.5”
PR Interval 0,16” 0,12” – 0,20”
QRS complex duration Normal 0,05” – 0,11”``
ST segmen Normal Normal / Elevated / Depressed
T wave Normal cQT = QT interval / vR-R’ Interval
U wave Absent Appear / not appear
Conclusion Sinus Rhythm, HR 76x/m, Normoaxis
 LABORATORIUM ERCP on March 14, 2024
Lab 25/3/24 Lab 10/3/24
Leu 18.95 Viral marker NR Endoscopy: Narrowing observed in the descending
Hb 9 part, with a mass showing dysplasia and fragility.
Tromb 456 Lab 22/3/24 Biopsy of 3 specimens was performed. Scope could
MCV 80.4 CEA 2.1 not be continued.
MCH 28.5 CA 19.9 138.7 Cholangiogram/Pancreatogram: Could not be
MCHC 35.4 performed.
PT 15.6/12.8 Conclusion:
INR 1.17/0.95 Obstructive jaundice, suspected adenocarcinoma in
APTT 29.4/29.8 the 2nd part of the duodenum with metastasis to the
SGOT 91 ampulla of Vater
SGPT 35
Ur 29
Cr 0.6
Na 136
K 3.9
Cl 90
GDS Stik 25/3/24 pukul
22.00 WITA 106
 PROBLEM LIST
• Hypovolemic shock resolved
• Controlled hypertension
• Obstructive jaundice with suspected
adenocarcinoma in the 2nd part of the duodenum
with metastasis to the ampulla of Vater differential
diagnosis pancreatic cancer with duodenal
metastasis
• Reactive leukocytosis with bacterial infection
differential diagnosis
• Reactive hepatopathy
No Problem list Pharmacological and Non Output and Outcome
Pharmacological Intervention

1 Hypovolemic shock Monitor vital signs every 1 hour, urine output Stabil hemodinamik
resolved every 24 hours, glucose monitoring 4 times a BP >90/60, HR<100
day BG>70
Intravenous fluids NaCl 0.9% 1000 cc: D10%
500 cc /24 hours
No Problem list Pharmacological and Non Output and Outcome
Pharmacological Intervention

2 Controlled hypertension Delay amlodipine 5 mg, etc. No hypotension

No Problem list Pharmacological and Non Output and Outcome
Pharmacological Intervention
3 Obstructive jaundice Check total and direct bilirubin. Check GGT. Diagnostic and evaluation test.
with suspected AFP, ALP, HDL cholesterol, LDL cholesterol Further workup from hepatology
adenocarcinoma in the Recommend MRCP or abdominal CT scan division
2nd part of the Consult Hepatology division
duodenum with
metastasis to the Consult Digestive Surgery.
ampulla of Vater
differential diagnosis
pancreatic cancer with
duodenal metastasis
No Problem list Pharmacological and Non Output and Outcome
Pharmacological Intervention

4 Reactive leukocytosis Ciprofloxacin 2x400 mg IV Initial antibiotic

with bacterial infection Metronidazole 3x500 mg IV Diagnostic test.
differential diagnosis Check urinalysis
Blood smear examination
Blood culture + sensitivity testing
No Problem list Pharmacological and Non Output and Outcome
Pharmacological Intervention

5 Reactive hepatopathy Check total and direct bilirubin. Check GGT. Evaluation test.
 CONCLUSION
• Has been reported the case of a 69-year-old man who
was admitted to R. D. Kandou Hospital at C1 ward with
the chief complaint of weakness. After a thorough
history-taking, physical examination, and laboratory-
radiology workup, patient was diagnosed with
Hypovolemic shock resolved, Controlled hypertension,
Obstructive jaundice with suspected adenocarcinoma
in the 2nd part of the duodenum with metastasis to
the ampulla of Vater differential diagnosis pancreatic
cancer with duodenal metastasis, Reactive leukocytosis
with bacterial infection differential diagnosis, Reactive
hepatopathy
 PROGNOSIS
• Ad vitam: dubia
• Ad functionam: dubia
• Ad sanationam: dubia