Observation Ascites

OBSERVATION ASCITES

Presented by “Digestive Surgery”

Supervisor : “dr. La Ode Rabiul Awal, Sp.B., Subsp., BD(K)., M.Kes”

Emergency Case Report Mei 2024

Genereal Surgery Division Departement of Surgery University of Halu Oleo

Patient’s Identity

Name : Duslan Age : 65 y.o Gender : Male

Religion : Moeslim Occupation : -

Address : Lanea Village Hospitalized : 21^th May 2024

Secondary Survey

Main Complaint:

Abdominal pain History Talking:

The patient came with left abdominal pain, felt 2 week ago. The complaint have been getting worse lately and swelling felt 1 week ago before came to the hospital. Patient also said the urine and feses colored like old tea. Patient has drink alcohol and smoking history.

Physical Examination

Generalist Status:

General condition : Moderate illness

Consciousness : E4V5M6 (Composmentis) Nutritional status : good

Vital Sign:

BP : 114/90 mmHg HR: 113x/minute RR: 22x/minute Temp : 36.3⁰C SpO2 : 96%

VAS : 3/10

Physical Examination

Present Status

 Head : normocephalic

 Eye : pupil isokor, Anemic conjunctiva (-/-), ikterik (-/-)

 Nose : rhinorrhea (-), epistaxis (-)

 Mouth: pallor (-), stomatitis (-), cyanosis (-)

 Ears : ottorhea (-)

 Neck : enlarged lymph nodes (-)

 Thorax: Symmetrical left and right, tenderness (-), mass (-), sonor (+/

+), vesicular breath sounds (+/+), wh (-/-), rh (-/-).

 Abdomen : follow breath, distended (-), peristalsis (+) increase impression, tenderness (+), tympanic (+)

 Upper estremities: warm acral, crt<2 sec.

 lower extremities : left (localized status), right (warm acral, crt<2 sec)

Physical Examination

Localized Status:

 Abdomen :

Inspection: Follow breath, distended (-).

Auscultation : Peristalsis (+) increase impression.

Palpation: Tenderness (+) , tenderness (+) regio lumbal sinistra,

Percussion : Tympanic (+).

Laboratory test

Hematology: (22/05/2024)

Item Find Satuan Nilai rujukan

WBC 6.6 10^3/µL 4.-10

RBC 2.57 10^6/µL 4.0-6.0

PLT 381 10^3/µL 150 - 400

Hb 8.1 g/dl 12-16

HCT 20.8 % 37-48

MCV 81.0 fL 80-97

MCH 31.40 pg 26.5-33.5

Radiology

Chest X-Ray:

 Impressions: Normal

USG:

 Impressions:

• Hepatomegaly

• Multiple solid lesions of the righ and left lobes of the liver, the largest size 7.1x6.9x7 cm in the left lobe, suspicious of

hepatoma.

• Buli sludge

• Prostate hyperthropy

• Ascites

Diagnosis

Working Diagnosis :

Observasi Ascites

Planning

― IVFD Ringer Lactat 20 tpm

― Inj. Pantoprazole 40 mg/24 jam/IV

Thank You