You are on page 1of 12

CHAPTER II CASE REPORT

II.1 ANAMNESIS (Autoanamnesis and Alloanamnesis) on January, 21th 2013 II.1.1. Identification Name Age Sex Address Status Occupation Religion Admitted to hospital II.1.2. Chief Complaint Enlargement of abdominal since 1 months before admission. II.1.3. History of Illness 1 months before admission, the patient complained of abdomen became larger. He also complained of abdominal fullness, no nausea, no vomit, loss of appetite, fatigue. He denied any complain of shortness of breath, abdominal pain, fever, swelling in palpebra superior, swelling in both of lower extremity. His urinate and feces like usuall. He wasnt get treated. 1 weeks before admission, the patient complained of abdomen became larger than before. He also complained of abdominal fullness, nausea but no vomit, loss of appetit dan fatigue. He also complained of swelling in both of lower extremity. He denied any shortness of breath fever and swelling in palpebra superior. His urine was tea color, his defecation like usuall. wasnt get treated : Mr. S : 57 years old. : Male : Desa Sidomulyo, Banyuasin. : Married : Rice farmer : Moslem : Januari 10st, 2013

1 day before admission, the patient complained of enlargement of abdomen became worse. He also complained of abdominal fullness, abdominal pain, nausea but no vomit, loss of appetite, fatigue and swelling in both of lower extremity. He denied any shortness of breath, fever and swelling in palpebra superior. His urine was tea color, his defecation like usual . He went to RSMH. II.1.4. History of Past Illness -

History of having same disease was denied. History of blood transfusion was denied. History of kidney disease was denied. History of foaming urine was denied. History of jaundice was denied. History of hypertension was denied. History of diabetes mellitus was denied. History of having same disease in family was denied. History of consuming herbs since 6 years, stop 15 years ago. History of consuming alcohol was denied

II.1.5. Family disease history II.1.6. Habitual history


-

II.2 PHYSICAL EXAMINATION (on January, 21th 2013) A. -

General examination General condition Sickness condition Consciousness Blood pressure Respiration rate Temperature Dehydration : (-) : 165 cm : sick. : moderate sickness. : compos mentis. : 110/70 mmHg. : 86 times/minute, regular. : 20 times/minute. : 36,70 C.

Pulse rate
-

Body height

Body weight Weight before ascites


-

: 60 kg : 55 kg : IMT= 20,2 % : Normowieght

Nutrition

B.

Abdominal circumferences : 95 cm Spesific examination

1. Skin Skin color is brownish, normal pigmentation, efloresence, icteric (-), pale on palm and plantar (-), scar (-), hyperhidrosis (-), normal hair growth, good turgor, wet or dry in palpitation (-), nodul subcutan (-) 2. Lymph gland There were no enlargement of the lymph nodes on submandibular, neck, axillaries and inguinal. 3. Head Normocephaly, symmetrical, deformity (-), alopecia (-). 4. Eye Eksophtalmus and enophtalmus (-), edematous palpebra superior (-), pale of conjunctiva palpebra (+/+), sclera icteric (-/-) 5. Nose Epistaxis (-), normal nasal septum and mucous layer 6. Ear Good hearing, normal both of meatus accusticus externus 7. Mouth Rhagaden of lips (-), stomatitis (-), papil atrophy (-),gum bleeding (-) 8. Neck Thyroid gland not palpable, thyroid bruit (-), jugular vein pressure (52) cmH20, hypertrophy of musculus sternocleidomastoideus (-), stiffness (-) 9. Thorax Normal shape, symmetrical, spider naevi (+), extended intercostal space (-), retraction (-), venectasis (-),.

Cor - Inspection - Palpation - Percussion : ictus cordis wasnt seen. : ictus cordis wasnt palpated. : upper boundary of cor is ICS II, right boundary of

cor is right parasternalis line, left boundary of cor is ICS V left midclavicularis line. - Auscultation : heart rate 86 times/minutes, regular, murmur (-), gallop (-). Lung - Inspection Palpation
- Percussion

: static, dynamic, right and left lung are symetric : Stem fremitus right lung = left lung : Sonor in both side of lungs.

- Auscultation : Vesicular (+) normal, ronchi (-), wheezing (-)

10. Abdomen

Inspection Palpation Percussion Auscultation

: convex, venectation (-), caput medusa (-). : distended, liver and spleen cant palpable, tenderness (-). : undulation (+), shifting dullness (+). : bowel sound (+) normal.

11. External genitalia : Not examined 12. Upper extremity Erythema of palm (+/+), pain on joint (-), pale on finger (-), pitting edema (-), clubbing finger (-), tremor (-), normal physiological reflex. 13. Lower extremity Varices (-), pretibial edema (+/+), pitting edema (+), clubbing finger (-), pain on joint (-), pale on finger (-), normal physiological reflex.

II.4 ADDITIONAL EXAMINATION Laboratory Examination January 10th 2013 Hematology


Hemoglobin Leucocyte Trombocyte Diff. Count

: 7,4 g/dl : 5.200/mm : 174.000/mm : 0/4/0/57/25/14 :+ :+

(N: 14-18 g/dl) (N: 40-48 vol%) (N: 5000-10000/mm) (N: 200000-500000/mm)

Hematocryte : 25 vol%

Immunoserology HbsAg Anti HCV January 11th 2013 Blood Chemistry


Cholesterol total HDL cholesterol LDL cholesterol Triglycerida Uric acid Ureum Creatinin Total Bilirubin Direct bilirubin Indirect bilirubin SGOT SGPT Protein total Albumin Globulin

: 125 mg/dl : 40 mg/dl : 90 mg/dl : 73 mg/dl : 3,8 mg/dl : 16 mg/dl : 0,9 mg/dl : 1,9 mg/dl : 0,77 mg/dl : 1,13 mg/dl : 55 U/L : 28 U/L : 7,4 g/dl : 1,9 g/dl : 5,5 g/dl

(N < 200) (N >55 ) (N<130) (N<150) (N: 3,5-7,1) (N: 15-39) (N: 0,9-1,3) (N: 0,1-1) (N: <0,25) (N: <0,75) (N: <40) (N: < 41) (N: 6.4-8.3) (N: 3.5-5.0) (N: 2.5-3.6)

Natrium Kalium Calsium

: 140 mmol/I : 3,7 mmol/I : 7,6 mmol/l

(N:135-155) (N: 3,5-5,5) (N:8,6-10,6)

Urinalysis Sediment - Epithel - Leucocyte - Eritrocyte - Cylinder


- Crystal

: Positive : 1-2 : 5-7 : Negative : Negative : Negative : Negative : Negative : Negative : Negative : Negative

(Positive) (0-5 FPV) (0-1 FPV)

: Negative

Bilirubin Urobilinogen Nitrit Blood Protein Keton Glucose Microbiology/ Faeces

Faeces consistency Colour Amoeba Erytrocyte Leucocyte Bacteria Worm egg Protein Lipid

: Soft

: Brown : Negative (Negative) : 0 - 1 (Negative) : 2 -3 (Negative) : Positive : Negative (Negative) : Negative (Negative) : Positive (Negative)

Occult Blood Test

: Negative (Negative)

Abdominal Ultrasonography (January, 15th 2013)

Interpretation : Liver shrink, hard parenchym, no mass, no cyst. Lien larger, pankreas normal. Ascites positive. Impression II.5 RESUME Mr.S,57 y.o, with enlargement of of abdomen became worse since 1 day before admission. 1 months before admission, the patient complained of abdomen became larger. He also complained of abdominal fullness, no nausea, no vomit, loss of appetite, fatigue. 1 weeks before admission, the : ascites (+), leading to cirrhosis hepatis.

10

patient complained of abdomen became larger than before. He also complained of abdominal fullness, nausea but no vomit, loss of appetit dan fatigue. He also complained of swelling in both of lower extremity. 1 day before admission, the patient complained of enlargement of abdomen became worse. He also complained of abdominal fullness, abdominal pain, nausea but no vomit, loss of appetite, fatigue and swelling in both of lower extremity. The patient has habitual history of consuming herbs since 6 years, stop 15 years ago. Physical examination, moderate sickness, compos mentis. BP 110/70 mmHg, PR 86 times/minute, reguler, RR: 20 times/minute, temperature 36,70 C, weight = 60 kg and height=152 cm, pale of conjunctiva palpebra. In thorax examination, spider naevi (+). Abdominal is distended, stiffness, hepar and lien are deifficult to examine, undulation. Pitting edema in both lower extremity, pale on palmar and plantar, erythema of palmar. Laboratory findings hemoglobin: 7.4 g/dl, hematocryte: 25 vol%, leucocyte: 5.200/mm, trombocyte: 174.000/mm, total bilirubin: 1.9 mg/dl, direct bilirubin: 0.77 mg/dl, bilirubin indirest 1,13 mg/dL, SGOT: 55 U/L, protein total: 6.2 g/dl, albumin: 7.4 g/dl, globulin: 5.5 g/dl, BSS: 88 mg/dl, HBs AG positive, Anti HCV positive. II.6 WORKING DIAGNOSIS Cirrhosis hepatis decompensata + anemia of chronic disease II.7 DIFFERENTIAL DIAGNOSIS Hepatocellular carcinoma + anemia of chronic disease Nephrotic syndrome + anemia of chronic disease Chronic kidney disease + anemia of chronic disease II.8 TREATMENT Nonpharmachology -

Bedrest Liver diet III

11

Pharmachology
-

IVFD D5% gtt XX/menit (micro) Spironolacton 3x100mg Furosemide inj 2x1 amp (20 mg) CaCO3 inj 3x500 mg Lactulac syrup 3x1c Curcuma syr 3x1c

II.9 PLANNING Fluid balance Albumin correction


Transfusion of PRC 580 cc

Rontgen thorax Prothrombine time Aspiration of ascites II.10 PROGNOSIS Quo ad vitam Quo ad functionam : dubia ad bonam : dubia ad malam

II.11 FOLLOW UP January, 11th 2013 Mr. S had weakness. Physical examination, from vital sign was in normal limit (sens: cm, BP: 120/70 mmHg, HR: 86 x/min, RR: 21 x/min, T: 36,50 C). Spesific examination, we found pale of conjungtiva (+), sclera icteric (-), JVP (5-2) cmH20. Thorax: spider naevi (+). Cor: HR 86x/min, reguler, murmur (-), gallop (-), Pulmo: vesicular (+) normal, rales (-), wheezing (-), Abdomen: convex, distended, liver and lien cant palpable, bowel sound (+) normal, undulation (+),

12

Extremities: palmar eritema (+), pitting edema (+) on lower extremity. Assessment was Cirrhosis hepatis decompensata + anemia of chronic disease. Planning: Fluid balance, abdominal USG, peripheral Blood Examination (MCH, MCV, MCHC), prothrombine time. Treatment: Bed rest, Liver diet III , IVFD D5% gtt XX/menit (micro), Spironolacton 3x100mg, Furosemide inj 2x1 amp (20 mg), CaCO3 inj 3x500 mg, Lactulac syrup 3x1c, albumin correction, transfusion of PRC 580 cc. January, 12th 2013 Mr. S had weakness. Physical examination, from vital sign was in normal limit (sens: cm, BP: 110/70 mmHg, HR: 84 x/min, RR: 20 x/min, T: 36,50 C). Spesific examination, we found pale of conjungtiva (+), sclera icteric (-), JVP (5-2) cmH20. Thorax: spider naevi (+). Cor: HR 84x/min, reguler, murmur (-), gallop (-), Pulmo: vesicular (+) normal, rales (-), wheezing (-), Abdomen: convex, distended, liver and lien cant palpable, bowel sound (+) normal, undulation (+), Extremities: palmar eritema (+), pitting edema (+) on lower extremity. Body weight: 60 kg, abdominal circumferences: 94cm, fluid balance: -600 cc. Laboratory, from hematology examination, Hemoglobin: 7,1 g/dl, Hematocryte: 24 vol%, Eritrocyte: 3.080.000/mm3, MCH : 23 pg, MCV:78 mcg, MCHC: 29%, Reticulocyte:2,6, Leucocyte:5800/mm3, Trombocyte: 160.000/mm3, Diff count: 0/4/1/61/21/13. Peripheral Blood Examination, Eritrocyte: microcytic hipochromic, Leucocyte: normally account and shape, Trombocyte: normally account and shape. Impression: microcytic hipochromic anemia, caused by chronic disease anemia.Assessment was Cirrhosis hepatis decompensata + anemia of chronic disease. Planning: Abdominal USG, transfussion of PRC. Treatment: Bed rest, Liver diet III, IVFD D5% gtt XX/menit (micro), Spironolacton 3x100mg, Furosemide inj 2x1 amp (20 mg), CaCO3 inj 3x500 mg, Lactulac syrup 3x1c. January, 16th 2013

13

Mr. S had shortness of breath. Physical examination, from vital sign was increase RR (sens: cm, BP: 100/70 mmHg, HR: 89 x/min, RR: 24 x/min, T: 36,60 C). Spesific examination, we found pale of conjungtiva (+), sclera icteric (-), JVP (5-2) cmH20. Thorax: spider naevi (+). Cor: HR 84x/min, reguler, murmur (-), gallop (-), Pulmo: vesicular (+) normal, rales (-), wheezing (-), Abdomen: convex, distended, liver and lien cant palpable, bowel sound (+) normal, undulation (+), Extremities: palmar eritema (+), pitting edema (+) on lower extremity. Body weight: 62 kg, abdominal circumferences : 95 cm, fluid balance: -150 cc. Laboratory, from blood chemistry, HDL cholesterol: 26 mg/dL, Total Bilirubin: 1,9 mg/dl, Direct bilirubin: 0,77 mg/dl, Indirect bilirubin:1,13 mg/dl, SGOT: 55 U/L, Albumin: 2,2 g/dl, Globulin: 4,9 g/dl, TIBC: 128 g/dl, Fe: 19 g/dL. Abdominal USG liver shrink, lien larger, ascites (+), leading to cirrhosis hepatis. Assessment was Cirrhosis hepatis decompensata + anemia of chronic disease. Planning: rontgen thorax, , transfusion of PRC. Treatment: Bed rest, Liver diet III, IVFD D5% gtt XX/menit (micro), Spironolacton 3x100mg, Furosemide inj 2x1 amp (20 mg), CaCO3 inj 3x500 mg, Lactulac syrup 3x1c, Curcuma syr 3x1c, Albumin correction. January, 19th 2013 Mr. S havent complaint, from vital sign was in normal limit (sens: cm, BP: 110/70 mmHg, HR: 84 x/min, RR: 20 x/min, T: 36,50 C). Spesific examination, we found pale of conjungtiva (+), sclera icteric (-), JVP (5-2) cmH20. Thorax: spider naevi (+). Cor: HR 84x/min, reguler, murmur (-), gallop (-), Pulmo: vesicular (+) normal, rales (-), wheezing (-), Abdomen: convex, distended, liver and lien cant palpable, bowel sound (+) normal, undulation (+), Extremities: palmar eritema (+), pitting edema (+) on lower extremity. Body weight: 60 kg, abdominal circumferences : 95 cm, fluid balance: -750 cc. Assessment was Cirrhosis hepatis decompensata + anemia of chronic disease. Planning: rontgen thorax,transfusion of PRC, aspiration of ascites. Treatment: Bed rest, Liver diet III, IVFD D5% gtt XX/menit (micro), Spironolacton 3x100mg,

14

Furosemide inj 2x1 amp (20 mg), CaCO3 inj 3x500 mg, Lactulac syrup 3x1c, Curcuma syr 3x1c.