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    MR Case Sulasiyah

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    Atar

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    MR Case Sulasiyah

    Uploaded by

    Atar
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    1 views15 pages

    MR Case Sulasiyah

    Uploaded by

    Atar

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 15

    Morning Report

    Friday Night Shift, November 8th, 2024

    Team : dr. Shinta (chief)


    dr. Farlina
    dr. Paulina S. N
    dr. Geleri
    dr. Jessi
    PATIENT IDENTITY

    ◦ Name : Mrs. S
    ◦ Age : 38 yo
    ◦ MR : 986595
    ◦ Clinical diagnose : Intraabdominal mass
    ◦ Chief complaint : Abdominal enlargement
    HISTORY TAKING
    The patient came in with complaint of an enlarged abdomen since 1 month ago and
    worsening since last week. Complaint were also accompanied by abdominal pain,
    especially when the patient walked. The patient also complained of vaginal discharge
    since 1 week ago. There was no nausea or vomiting. There is a history of fever before
    admitted to the hospital.

    The patient was referred from Labuang Baji Hospital with a diagnosis of Giant Epidermoid
    cyst intraabdomen + CKD Grade IV + severe cancer pain + Anemia and has received
    ceftriaxone, fentanyl, omeprazole therapy and has received a transfusion of 5 bags of PRC
    Urination within normal limit. Defecation within normal limit, flatus (+) this afternoon
    There is no history of diabetes
    There is no history of hypertension.
    There is a history of CKD, since 2019.
    History of Cimino implantation on the left arm at Labuang Baji Hospital, September 2024.
    History of CAPD insertion in 2019, removed 1 week ago at Labuang Baji Hospital, due to
    infection.
    History of routine dialysis 3 times a week (Monday, Wednesday, and Friday)
    PHYSICAL EXAMINATION

    General status : Compos Mentis/ GCS 15 (E4 M6 V5)


    Blood pressure : 112/82 mmHg
    Heart Rate : 92 times/minute
    Respiratory rate : 20 times/minute
    Temperature : 36.5C
    •SpO2 : 99% with room air
    Localized Status

    Regional Abdomen:

    I: Convex, there is a mass visible, bowel stiffness (-), bowel contour (-)
    A: Peristalsis is present, within normal limit
    P: A mass is palpable from the left lumbar region, measuring 10x8cm, hard consistency, flat surface, fixed, no
    tenderness.
    P: Tymphany

    Anal examination:

    Spichter ani within normal limit, smooth mucosa, empty ampulla


    Handschoen: Feces (-) mucus (-), blood (-)
    LABORATORY FINDINGS
    Routine Blood Test Renal Function Test
    WBC : 12.4 ( 4.00 – 10.0 10³/ ul ) Ureum : 68 ( 10 -50 mg/dl)
    HGB : 8.5( 12.0 – 16.0 gr/dl) Creatinin : 4.11 ( L < 1.3 P < 1.1 mg/dl )
    HCT : 26 ( 37.0 – 48.0 %)
    PLT : 230 (150-400 10³/ ul ) Liver Function Test
    Neut : 52.3 (52,0 – 75,0 %) GOT : 26 u/L(<38)
    Lymp : 35.1 (20.0-40.0 % ) GPT : 13 u/L (<41)

    Electrolytes GDS: 98 mg/dl (<200mg/dl)


    Natrium : 134 (136-145 mmol/l)
    Calium : 4.3 (3.5 – 5.1 mmol/l)
    Chlorida : 101 (96-106)
    NON ENHANCED MSCT SCAN OF THE ABDOMEN
    08-11-2024
    NON ENHANCED MSCT SCAN OF THE ABDOMEN
    08-11-2024
    An MSCT Scan of the abdomen without contrast was performed on axial, sagittal and coronal reformatted slices with the following results:

    • Heterogeneous mass (12-68 HU) predominantly cystic with well define border, regular edges, calcified with dimensions of +/- 24.4 x 12.9 x 14.3 cm, impression on the pelvic cavity extending
    into the abdominal cavity impression from adnexal region shifting the surrounding organs and infiltrating the anterior abdominal wall.

    •Liver: Not enlarged, regular surface, sharp tip, parenchymal density within normal limits. No intra and extra-hepatic vascular and bile duct dilatation is seen. No visible SOL density/metastatic
    nodules

    • Gallbladder: The walls are not thickened, the mucosa is regular, no visible stone density
    • Pancreas: Shape, size and density of parenchyma within normal limits. No visible dilatation of pancreatic ductus. No visible mass/cyst
    • Spleen: Not enlarged and parenchymal density within normal limits. No visible SOL density/metastatic nodules.
    • Right kidney: Small size, density within normal limits. No visible PCS dilatation. No visible stone density. Hypodense lesion (19 HU) with clear boundaries, regular edges with dimensions of
    +/- 2.28 x 1.65 x 2.28 cm in the parenchyma.

    • Left kidney: Small size, density within normal limits. No visible PCS dilatation. No visible stone density. Hypodense lesion (19 HU) well define border, regular edges with dimensions of +/1.25
    x 1.04 x 1.34 cm in the parenchyma

    • Vesica Urinaria: Minimal urine (difficult to evaluate)


    •Uterus: Anteflection position, parenchymal density within normal limits. No SOL density/metastatic nodules are visible. There is density copper T inside
    • No abdominal paraaortic lymph node enlargement is visible
    • Free fluid density (14HU) in the peritoneal cavity
    •Diffuse osteosclerotic. Osteophytes on the anterolateral aspect of the scanned CV T12 and T10 (Thoracic spondylosis). Other bones intact.
    NON ENHANCED MSCT SCAN OF THE ABDOMEN
    08-11-2024

    Impression:

    •Adnexa complex mass


    •PNC with bilateral renal cysts
    •Ascites
    •Renal osteodistrophy
    Thank You
    FOTO POLOS ABDOMEN RSWS
    10-10-24
    CT SCAN ABDOMEN RS LABUANG BAJI 6-11-24

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