Scenario C Blok XI Batch 2020

Learning Objective
Through this scenario students are supposed to be able to:
1. Explain anatomy, histology, biochemistry and physiology of hepatobiliary system.
2. Explain the etiology of Icteric (obstructive and non obstructive)
3. Explain the pathophysiology of icteric
4. Explain additional examination for this case
5. Explain Determining Diagnosting and differential diagnostic of icteric
6. Explain Treatment, complication and prognosis for this case
7. Knowing the competence of general practicioner of this case
8. Islamic Point of view regarding the case.

“YELLOWISH EYE”

Mrs. M , 48 years old came to the emergency department with a chief complain upper right
abdominal pain since 5 days ago. The complain followed with yellowish eyes, Urinate colored like dark tea,
defecate like white fecal matter, itchy skin, up and down fever, but its not too high since two weeks ago.
Mrs. M also complain her body feels weak, epigastric pain, and reduced appetite.
Mrs.M didn’t have history of consuming drugs on a long period of time. Mrs. M didn’t have
medical history of contracting Hepatitis B since birth. Since 3 month Mrs. M experiencing a pain on her right
upper abdomen that radiates to the right back, especially after consuming Padang food.
Physical Examination:
General Appearance: looks moderately sick, conciousness compos mentis.
Vital Sign: BP 110/80 mmHg; Pulse 100x/m; RR 22x/m, Temp 37,8oC.
BW 75 kg, BH 160 cm.

Specific Examination:
Head : Pale conjungtive (-/-), Icteric Sclera (+/+)
Neck : JVP 5-2 cmH2O, theres no enlargement on the neck
Thorax :
Thorax wall: normal
Pulmo:
- Inspection: symetric static and dynamic
- Palpation: same stem fremitus left and right
- Percussion: sonor on the whole lung
- Auscultation: vesikuler (+/+). Ronkhi (-/-), wheezing (-/-)
Cor:
- Inspection: flat, ictus cordis (-)
- Palpation: ictus cordis were not palpable
- Percussion; normal heart border
- Auscultation: HR 100x/m, reguler, heart sound I-II normal
Abdoment :
- Inspection: flat, caput medusa (-). Cullen sign (-), grey turner sign (-)
- Auscultation: normal bowel sound
- Percussion: shifting dullness (-)
- palpation: supple, Murphy sign (+), hepar were not palpable, lien S1, ballotement (-/-)
- Ekstremity : edema pretibia (-), palmar eritem (-), yellow skin.

Laboratory Examination:
- Hb 12,3 g/dl - Albumin 3,8 mg/dl
- Ht 36 vol %
- Leukosit : 15.600/mm3
- Trombosit 180.000/mm3
- LED : 100 mm/hour
- Bil tot : 18,2 mg/dl
- Bil direk : 17,6 mg/dl
- Bil indirek : 0,6 mg/dl
- SGOT : 80 u/L
- SGPT : 96 u/L
- Fosfatase alkali : 510 u/L
- HBs Ag (-)
Urinalysis: bilirubin urin (+)

I. Term Clarrification
1. upper right abdominal pain 10. Murphy sign
2. Yellowish eyes 11. covousier sign
3. Dark tea collored urine 12. Ballotement
4. defecate like white fecal matter 13. shifting dullness
5. Epigastric pain 14. edema pretibia
6. Icteric Sclera 15. palmar eritem
7. caput medusa 16. Bilirubin total
17. Bilirubin direk
8. cullen sign
18. Bilirubin indirek
9. grey turner sign

II. Problem Identification

1. Mrs. M , 48 years old came to the emergency department with a chief complain upper right
abdominal pain since 5 days ago.
2. The complain followed with yellowish eyes, Urinate colored like dark tea, defecate like white fecal
matter, itchy skin, up and down fever, but its not too high since two weeks ago.
3. Mrs. M also complain her body feels weak, epigastric pain, and reduced appetite.
4. Mrs. M didn’t have history of consuming drugs on a long period of time. Mrs. M didn’t have
medical history of contracting Hepatitis B since birth. Since 3 month Mrs. M experiencing a pain on
her right upper abdomen that radiates to the right back, especially after consuming Padang food.
5. Physical Examination:
General Appearance: looks moderately sick
Vital Sign: Pulse 100x/m, Temp 37,8oC.
BW 75 kg, BH 160 cm.
Specific Examination:
Head : Icteric Sclera (+/+)
Neck : JVP 5-2 cmH2O, theres no enlargement on the neck
Abdoment :
- Inspection: flat, caput medusa (-). Cullen sign (-), grey turner sign (-)
- Auscultation: normal bowel sound
- Percussion: shifting dullness (-)
- palpation: supple, Murphy sign (+), hepar were not palpable, lien S1, ballotement
(-/-)
Ekstremity : edema pretibia (-), palmar eritem (-), yellow skin.

6. Laboratory Examination:
- Hb 12,3 g/dl
- Ht 36 vol %
- Leukosit : 15.600/mm3
- Trombosit 180.000/mm3
- LED : 100 mm/hour
- Bil tot : 18,2 mg/dl
- Bil direk : 17,6 mg/dl
- Bil indirek : 0,6 mg/dl
- SGOT : 80 u/L
- SGPT : 96 u/L
- Fosfatase alkali : 510 u/L
- HBs Ag (-)
- Albumin 3,8 mg/dl

Urinalysis: bilirubin urin (+)

III. Problem Analysis
1. Mrs. M , 48 years old came to the emergency department with a chief complain upper right
abdominal pain since 5 days ago.
a. What is the meaning of chief complain upper right abdominal pain since 5 days ago?
b. What is the possible related organ regarding this cases? (hepar, billiary tract, gallbladder)
c. What is the anatomy, histology, physiology of hepatobillier system?
d. How is reletionship between age and gender with its complains?

2. The complain followed with yellowish eyes, Urinate colored like dark tea, defecate like white
fecal matter, itchy skin, up and down fever, but its not too high since two weeks ago.
a. What is the meaning complain followed with yellowish eyes, Urinate colored like dark tea,
defecate like white fecal matter, itchy skin, up and down fever, but its not too high since two
weeks ago? (meanining there is a total obstruction of hepatobiliary system)
b. What is possible etiology the complains?
c. What are the possible etiology of icteric from hepatobillier system? (icterus obstruktive and
icterus non obstruktive)
d. What is the possible etiology of yellowish eyes in this case? (there is an obstruction of
hepatobiliary system)
e. What is the patophysiology of Urinate colored like dark tea, defecate like white fecal matter,
itchy skin, up and down fever, but its not too high?
f. What is the possible etiology of up and down fever, but its not too high? ( inflamation of
gallbladder and biliary track)

3. Mrs. M also complain her body feels weak, epigastric pain, and reduced appetite.
a. What is the possible etiology of feels weak, epigastric pain, and reduced appetite?
( inflamation of gallbladder and biliary track)

4. Mrs. M didn’t have history of consuming drugs on a long period of time. Mrs. M didn’t have
medical history of contracting Hepatitis B since birth. Since 3 month Mrs. M experiencing a pain
on her right upper abdomen that radiates to the right back, especially after consuming Padang
food.
a. What is the meaning of didnt have history of consuming drugs on a long period of time?
(differentiating medicamentosa hepatotoxicity)
b. What is the meaning of didn’t have medical history of contracting Hepatitis B since birth?
(differentiating transmission of hepatitis B)
c. What is the meaning Mrs. M experiencing a pain on her right upper abdomen that radiates to
the right back, especially after consuming Padang food? ( bilier colic)

5. Physical Examination:
General Appearance: looks moderately sick
Vital Sign: Pulse 100x/m, Temp 37,8oC.
BW 75 kg, BH 160 cm.
Specific Examination:
Head : Icteric Sclera (+/+)
Neck : JVP 5-2 cmH2O, theres no enlargement on the neck
Abdoment :
Inspection: flat, caput medusa (-). Cullen sign (-), grey turner sign (-)
Auscultation: normal bowel sound
Percussion: shifting dullness (-)
palpation: supple, Murphy sign (+), hepar were not palpable, lien S1, ballotement (-/-)
 Ekstremity : edema pretibia (-), palmar eritem (-), yellow skin.
a. How is the interpretation and mechanism of abnormal physical examination?
b. How is abdominal physical examination in this case?

6. Laboratory Examination
- Hb 12,3 g/dl
- Ht 36 vol %
- Leukosit : 15.600/mm3
- Trombosit 180.000/mm3
- LED : 100 mm/hour
- Bil tot : 18,2 mg/dl
- Bil direk : 17,6 mg/dl
- Bil indirek : 0,6 mg/dl
- SGOT : 80 u/L
- SGPT : 96 u/L
- Fosfatase alkali : 510 u/L
- HBs Ag (-)
- Albumin 3,8 mg/dl

Urinalysis: bilirubin urin (+)

a. How is the interpretation and mechanism of abnormal Laboratory Examination?

b. How is Mechanism of abnormal Laboratory Examination?
c. How is the metabolism of billirubin?

7. What is the differential diagnosis of this case?

- Acute colangitis
- Acute colesistitis
- Koledokolitiasis
- Acute pancreatitis
- Malignancy of biliary sistem ( Kolangio carcinoma caput pangkreas)

8. What are the needed additional examination for this case? (abdominal USG,MRCP, Amilase
examination, Lipase, CA19-9)
9. What is the diagnosis of this case ? (Acute colangitis ec Koledokolitiasis)
10. How to treat this case comprehensively? (reduce pain and infection, refer to related specialist)
11. What is the possible complication? (sepsis, liver failure)
12. How is the prognosis of this case?
13. What is the competence of general practicioner of this case?
14. What are the islamic point of view of this case?

IV. Hypotesis and Conceptual Framework

Hypotesis
Mrs. M, 48 years old complain upper right abdominal pain since 5 days ago because of suffering
acute colangitis ec coledocolitiasis
Conceptual Framework

Risk Factor (female, Forty (48 years olad), fat)

Gallbladder stone

Colic biliarry

Stone descends into coledocus duct

coledocus duct inflammation (colangitis)

fever, upper right abdominal pain , icteric (trias charcot)

Nilai-nilai Islam (Skenario C Blok 11)
(Tutor menyebutkan nama surat dan ayat Alquran atau hadist yang diriwayatkan kepada mahasiswa pada
lembaran ini di hari pertama. Pada hari kedua, mahasiswa membacakan dan membahas ayat Alquran atau
hadist tersebut terkait kasus)

Dilihat penyebabnya, sakit kuning ini dapat terjadi karena faktor antara lain; Genetic, Penyakit
autoimun, Virus hepatitis, Minum al-kohol, dan sebagainya.
1. Faktor genetik
Sebelum melakukan pernikahan, Islam menganjurkan agar memilih calon suami atau isteri
sebagai pasangan hidup yang baik, nanti akan meneruskan keturunan yang baik pula. Oleh
karena itu Nabi SAW memberikan kreteria memilih jodoh tersebut antara lain karena hasab
yang bisa berarti keturunan atau genetik. Sebagaimana sabda Nabi SAW:
ِ ِ ِ ِ ‫هِل‬ ‫ِ هِل حِل‬
ْ َ‫ ل َمـا َا َو َ َسـبِ َها َوجِلَ َمـا َا َولديْن َهــا فَ اظْ َف ْر بِ َذات ال ِّديِ ِن تَـ ِرب‬, ‫َأِلربَــ ٍع‬
‫(رواه البخ اري و‬.‫ت يَ َداك‬ ْ ُ‫ـح اْملَ ْرَأة‬
ُ ‫ُتْن َك‬
)‫مسلم‬
Artinya: Perempuan itu dinikahi karena empat perkara; karena hartanya, karena
keturunannya, karena kecantikannya dan karena agamanya. Tetapi utamakanlah karena
agama, agar selamat dirimu.(HR.Bukhari-Muslim).
2. Faktor Autoimun
Sesungguhnya seseorang yang memiliki ketahanan tubuh (imun) yang kuat, itu dianjurkan
oleh Islam, karena itu harus memelihara kebugaran tubuh sehingga menjadi kuat, jasmani
dan rohani. Hal ini sesuai dengan hadits Nabi SAW dari Abu Hurairah:
ِ ِ‫ب ِإىَل اللَّ ِه ِمن الْمْؤ ِم ِن الضَّع‬
‫يف‬ ُّ ‫َأح‬ ُّ ‫الْ ُمْؤ ِم ُن الْ َق ِو‬
ُ َ َ ‫ى َخْيٌر َو‬
Artinya : mukmin yang kuat lebih baik dan lebih dicintai oleh Allah daripada mukmin yang
lemah.(HR. Muslim no.6945)
3. Faktor Virus
‫ ُْأر ِس َل َعلَى طَاِئَف ٍة ِم ْن بَىِن‬،‫س‬ ِ َّ َّ ِ ِ ‫ قَ َال رس و ُل‬:‫ث ُأس امةَ بن زي ٍد قَ َال‬
َّ َ ‫اهلل‬ ِ
ٌ ‫ص لى اهللُ َعلَْي ه َو َس ل َم “اَلطاعُ ْو َن ر ْج‬ ُْ َ ْ َ ُ ْ َ َ ُ ْ‫َح دي‬
‫ض َوَأْنتُ ْم هِبَا فَاَل خَت ُْر ُج ْوا‬
ٍ ‫ َوِإذَا َوقَ َع بِ َْأر‬.‫ض فَاَل َت ْق َد ُم ْوا َعلَْي ِه‬
ٍ ‫ فَِإذَا مَسِ ْعتُ ْم بِِه بِ َْأر‬،‫ َْأو َعلَى َم ْن َكا َن َقْبلَ ُك ْم‬،‫ِإ ْسَراِئْيل‬
َ
”ُ‫كم ِإاَّل فِرارا ِمْنه‬ ٍ ِ ‫ ىِف‬.‫فِرارا ِمْنه‬
ً َ ْ ُ ‫(و ر َوايَة) اَل خُيْ ِر ُج‬ َ ُ ًَ
Artinya: 1433. Usamah bin Zaid r.a. berkata: “Rasulullah saw. Bersabda: “Tha’un (wabah
cacar) itu suatu siksa yang diturunkan Allah kepada sebagian Bani Isra’il atau atas umat yang
sebelummu. Maka bila kamu mendengar bahwa pentakit itu berjangkit di suatu tempat,
janganlah kalian masuk ke tempat itu, dan jika di daerah di mana kamu telah ada di sana maka
janganlah kamu keluar dari daerah itu karena melarikan diri dari padanya”. ”. 1
Islam meletakkan suatu kaidah kesehatan yang sangat penting untuk mengantisipasi
penyakit menular, seperti kolera, tha’un, dan sopak. Kaidah-kaidah ini tidak berbeda dengan
nilai-nilai sains modern dewasa ini. Apabila kita mengetahui perkembangan kesehatan, maka kita
akan mengetahui jika terjadi wabah kolera, atau sopak di suatu kota, maka buatlah pengaman di
sekitarnya. Kemudian dengan alasan apapun, tak seorang pun didizinkan memasukinya, kecuali
para petugas kesehatan atau orang yang mempunyai kepentingan di dalamnya, itu pun mesti di
bawah pengawasan Departemen Kesehatan.

1
Muhammad Fu’ad Abdul Baqi, Al-Lu’lui wal Marjan,  (Surabaya: PT. Bina Ilmu, 2006), 853-854
 Suatu ketika Umar bin Khattab hendak mengunjungi Syam bersama para sahabat. Maka
Abu Ubaidah, Gubernur Syam pada waktu itu, keluar untuk menjemputnya di jalan dan
menyampaikan kepadanya bahwa di negeri ini sedang berjangkit wabah penyakit tha’un, maka
Umar pun bermusyawarah dengan para sahabat yang mengikutinya. Di antara mereka ada yang
mengusulkan agar tetap ke Syam dan tidak membatalkan atau tidak lari dari qadar Allah.
Sebagian yang lain mengusulkan agar kembali dan tidak menghadapkan kaum muslimin dan para
sahabat itu ke dalam lingkungan yang terjangkit wabah tha’un itu. Mereka berpendapat bahwa
lari dari qadar Allah kepada qadar Allah.
Akhirnya datang seorang sahabat menyampaikan sebuah hadits yang didengar dari
Rasulullah saw. Maka mereka kembali ke Madinah, sedangkan penduduk Syam diperintahkan
agar tidak meninggalkan daerahnya sehingga wabah itu benar-benar hilang. 2
4. Al-kohol
Mengkonsumsi alkohol itu lebih banyak mudhorat daripada manfaat, bahkan dapat
menyebabkan timbulnya penyakit. Sehubungan dengan itu, Allah SWT berfirman di dalam
QS 2 al-Baqarah ayat 219:
‫َأك َب ُر ِم ْن‬ ِ ‫يه َم ا ِإ مْثٌ َك بِ ريٌ َو َم نَ افِ ُع لِ لن‬
ْ ‫َّاس َو ِإ مْثُ ُه َم ا‬ ِ ِ‫ قُ ل ف‬Jۖ ‫ك َع ِن ا خْلَ ْم ِر و الْ م ْي ِس ِر‬
ْ َ َ َ َ‫يَ ْس َألُ ون‬
ِ ‫ك ي ب نِّي اللَّه لَ ُك م ا آْل ي‬ ِٰ َ ‫اذ ا يُ ْن ِف ُق‬
‫َّك ْم‬
ُ ‫ات لَ َع ل‬ َ ُ ُ ُ َ ُ َ ‫ َك َذ ل‬Jۗ ‫ون قُ ِل الْ َع ْف َو‬ َ ‫ك َم‬ َ َ‫ َو يَ ْس َألُ ون‬Jۗ ‫َن ْف عِ ِه َم ا‬
‫ون‬
َ ‫َت َت َف كَّ ُر‬
Artinya : mereka bertanya kepadamu tentang khamar3dan judi. Katakanlah: "Pada keduanya
terdapat dosa yang besar dan beberapa manfaat bagi manusia, tetapi dosa keduanya lebih
besar dari manfaatnya".
Itulah sebabnya Islam mengharamkan meminum alkohol meskipun sedikit, sebagaimana
sabda Nabi di dalam kitab shahih Muslim:
‫ُك ُّل ُم ْس ِك ٍر َحَر ٌام َو ُك ُّل ُم ْس ِك ٍر مَخٌْر‬
Artinya : “Semua yang memabukkan adalah haram, dan semua yang memabukkan adalah
khamr.”  (HR. Muslim melalui Ibnu Umar)
Demikian juga Imam At-Tirmidzi, An-Nasa’i, dan Abu Dawud meriwatkan melalui
sahabat Jabir bin Abdillah bahwa Nabi saw. bersabda:
‫ماَ اَ ْس َكَر َكثِْيُرهُ َف َقلِْيلُهُ َحَر ٌام‬
Artinya : “sesuatu yang memabukkan bila banyak, maka sedikit pun tetap haram”. (HR.
Imam At-Tirmidzi, AN-Nasa’I, dan Abu Dawud)

2
Ahmad Syauqi Al-Fanjari, Nilai Kesehatan dalam Syari’at Islam, (Jakarta: Bumi Aksara, 1996), hal.40-41
3
Segala minuman yang memabukkan