Patient was auto-anamnesed on Tuesday, 11 Sept 2012 at 14.

00 pm

Identity
Name
Age Sex

Address
Occupation Religion Marital Status Race Education

: Mr. W : 56 years old : Male : Bayur Lor 11/04, Kampung Bayur Lor : Labour : Moeslem : Married : Sundanese : Elementary School

Main Complaint Additional Complaint

abdominal swelling since 1 months before admitted to hospital

Shotness of breath when stomach fell Fever since 2 days before admitted to hospital Dry in throat Cough since 1 month before admitted to hospital

 Mr. W came to the Emergency Department of Karawang

State Hospital with abdominal swelling since 1 months ago before admitted to the hospital. He complained his abdomen getting. He also complained dizziness, nausea, and weakness. 1 months before, he complained his nails, until the whole body becomes yellow Sometimes he had a fever, and cough since 1 month ago but never vomited blood and found black in feces.

History of treatment
He said this is the first treatment in hospital, when he get

sick before

Same symptomps () Liver disease (-)

hypertension (-)
Heart disease (-)

Allergy (-)

Kidney disease (-)

Dyspepsia syndrome (-)

Cancer (-)

Diabetes mellitus (-)

Family history
Same symptomps () Liver disease (-)

hypertension (-)
Heart disease (-)

Allergy (-)

Kidney disease (-)

Dyspepsia syndrome (-)

Cancer (-)

Diabetes mellitus (-)

Personal and Habitual Story

He eats at least once daily, likes vegetables and fruits.
He seldom does physical exercise He never consumes alcohol

He smokes since he was young until he got a sick

Appearance
Consciousness Nutritional status

: moderately ill
: compos mentis : 160cm,50kg

Vital Sign
Blood pressure
Heart rate Respiration rate Temperature

: 120/80 mmHg
: 80x/min : 24 x/min : 36,1C

Head Eyes

Normochepaly, black hair, good distribution

Anemic conjungtiva -/-,Icteric sclera -/ Hiperemic (-/-), tenderness (-/-), secret (+/+) Septum deviation (-), hiperemic concha (-/-), secret (-/-), mass (-/-), nostril breathing (-) Red lip (+) dry (-). Carries (+) on M1-2 left and right. Tongue (N). Arcus faring (N). Tonsil (N). Posterior Pharyng (N) (-), Limf node: enlargement tenderness (-) Thyroid: enlargement (-), tenderness (-) JVP: 5+1 cmH2O

Ears
Nose Mouth

Neck

ThoraxINSPECTION Examination- Lung

Ictus cordis is invisible
PALPATION Ictus cordis is palpable at 5th ICS LMCS

PERCUTION Right heart border: ICS III-V LSD Left heart border: ICS V 1cm medial LMCS Upper heart border: ICS III LPSS AUSCULTATION Regular I - II absence of murmurs and gallop in hearts sound

Thorax INSPECTION Examination-Heart

Ictus cordis is invisible
PALPATION Ictus cordis is palpable at 5th ICS LMCS

PERCUTION Right heart border: ICS III-V LSD Left heart border: ICS V 1cm medial LMCS Upper heart border: ICS III LPSS AUSCULTATION Regular I - II absence of murmurs and gallop in hearts sound

Abdomen Examination INSPECTION

Brown skin hipopigmentation in umbilicus regio , distended, caput medusae -, spider nevy PALPATION pain + on epigastrim regio, undulation +, liver and lien not palpable PERCUSSION pain on percution -, shifting dullness + AUSCULTATION Bowel sound +, arterial bruit -, Venous hum -

Extremity
+
Warm acrals

Oedem

+ pitting

+ pitting

Laboratory Examination
Haematology Haemoglobin Leukocyte Trombocyte Haematocryte Basophil Result 14,1 gr/dL 5700 198.000 43 % 0% Normal Value

12-17 gr / dL

5.000 10.000
150.000 450.000 37-48 % 0-1 %

Eosinophil
Neutrophyls Rod Neutrophyls Segment Limphocytes

0%
0% 70 % 14%

1-3 %
2-6 % 40-70 % 20-40 %

Monocytes

5%

2-8 %

Haematology HbsAg Blood Sugar Ureum Creatinin Total Protein Albumin Globulin Total Bilirubin Direct Bilirubin Indirect Bilirubin

Result 82 mg/dL 36,8 mg/dL 1,27 mg/dL 8,36 mg/dL 2,58 mg/dL 5,78 mg/dL 3,51 mg/dL 2,76 mg/dL 0,75 mg/dL

Normal Value 80-140 mg/Dl 10-45 mg/dL 0,4-1,5 mg/dL 6,5-8,5 mg/dL 3,5-5,0 mg/dL 2,6-3,6 mg/dL < 1,1 mg/dL < 0,6 mg/dL < 0,5 mg/dL

SGOT SGPT

200 mg/dL 59 mg/dL

< 40 mg/dL < 40 mg/dL

Pemeriksaan USG
Hepar

: tidak membesar, enchoparenchym meningkat, tak tampak nodul Pankreas : Gail bladder, Lien tidak membesar, tak tampak nodul atau batu Ginjal : kanan dan kiri tidak membesar, batas sinus cortex kabur, tak tampak batu Buli-buli : kesan normal Tampak adanya cairan intraabdomen Kesimpulan : SH + ascites + Nephritis bilateral

Resume
History Taking

abdominal swelling since 1 months before admitted to hospital Shotness of breath when stomach fell Fever since 2 days before admitted to hospital Dry in throat Cough since 1 month before admitted to hospital Blood found in feces

Physical Examination
icteric sclera +/+ distended abdomen, ascites pain on epigastric +, undulation + shifting dullnes + edema on lower extremitiy + (pitting)

Laboratory Examination
albumin globulin total bilirubin direct bilirubin indirect bilirubin SGOT SGPT dark urin black stool

Differential Dignosis
Cirrhosis Hepatis ec Susp Alcoholic Hepatitis
Cirrhosis Hepatis ec Drug Induced Hepatitis

Cirrhosis Hepatis ec Susp Hepatitis C

Cirrhosis Hepatis ec Alcoholic Fatty Liver

Working Diagnosis
Chirrosis hepatis stadium dekompensata ec Hepatitis B

Suggested Examination
Liver Biopsy
Esophagoscopy Cholesterol, Trigliseride, LDL, HDL

Anti HcV
Protrombine time

Medication
Dextrose 5 % 10 dpm Albumin (20%) 1 fl (24 hour first) Lasix 2x1 amp Spironolakton 100 mg 2x1 Cefotaxim 2x1 amp Ranitidin 2x1 amp Propanolol 10 mg 3x1 Vitamin K 3x1

Non-Medication Therapy
Bed rest
high calorie

Prognosis
Ad Vitam
Ad Functionam Ad Sanationam

: Dubia Ad Malam : Dubia Ad Malam : Dubia Ad Malam