CASE

PRESENTATION

Riantika Nur Utami 30101407303

Advisor :
dr.HM. Saugi Abduh, Sp.PD, KKV, FINASIM
 PATIENT’S IDENTITY

Name : Mr ZA
Age : 55 years old
Sex : Male
Religion : Moslem
Job : Farmer
Address : jl. KH Syamsuri 02/06 Gaji Guntur Demak
No. RM : 01366xxx
Room : Baitul Izzah 1 / I3
Entry Date : 23 October 2019
Date Out : 29 October 2019
 HISTORY TAKING
History of Present Illness
Patient come to RSI Sultan Agung with complaints of
abdominal pain. Pain felt disappear and arise, especially in
the upper right abdomen and spread throughout the right
Main waist, pain is dull. Patients admitted the abdominal pain felt
more frequently before entering the hospital. Abdominal pain
Problem has been experienced by patients for 2 months and heavy
“Abdominal increasingly in two days. The patient also complains that his
Pain” stomach is often bloated, discomfort and hard two months
increasingly enlarged. In addition the patient also complain
of weakness, fatigue and dizziness, nausea and vomiting,
loss of appetide, and drastic weigh loss for about 2 month.
There are no urine concentrated like tea, vomitting blood and
black/bloody stool or pale stool.
 SYSTEMIC ANAMNESIS

Onset : 2 months ago

Location : right upper quadran
Chronology : Abdominal pain has been experienced by
Chief patients for 2 months and heavy increasingly in two days. The
complai patient also complains that his stomach is often bloated,
nt discomfort and hard two months increasingly enlarged
Quality and Quantity : pain is dull, pain is dissappear & arise
“Abdomi Modification factor : -
nal Pain”  Comorbid complains : weakness, fatigue and dizziness, nausea
and vomiting, loss of appetide, and drastic weigh loss for about 2
month.
 HISTORY OF ILLNESS

History of previous Sosio – Economic History

illness Family’s history of disease

• Same symptom/illness
(-)
• Hypertension history • Hypertension history (+)
(-) • Economic Impression :
• DM history (+)
• DM history (-) enough
• Asthma (-)
• Asthma history (-) • Hospital cost certified by
• Alergy history (-)
• Alergy history (-) JKN PBI
• Cardiac Disease (-)
• Drug allergy (-)
• Smoking history (-)
• Patient say that he always
consumed “jamu” for 2
months since he was sick
 24 - 19
GENERAL STATUS 20

General Status Vital Sign BMI

weakness 127/84 mmHg 48 kg

Composmentis 87 x/minute
168 cm

20 x/minutes 48
_____
= 17.2
(1,68)2
36,5 0C
Interpreta
tion
100%

• Underweight
 PHYSICAL 
EXAMINATION
 24 - 19
GENERAL PHYSICAL EXAMINATION 10

Anemic conjuntiva (-/-) - • Mesocephal (+)

Icteric sclera (-/-) – • Alopesia (-)
• Rambut jagung (-)

Symmetric -
• Normal shape
Secret (-) -
• Discharge (-/-)
Nostril Breath (-) -

Cyanosis (-) - • Tracheal deviation (-)

dry lips (-) - • Lymph hypertrophy (-)
snoring (-) -
Interpreta
tion
• Normal
 24 - 19
THORAX-LUNG EXAM 10

PHYS. EX ANTERIOR POSTERIOR

• RR : 20x/min - Pectoral • RR : 20x/min - Pectoral
muscle atrophy (-) muscle atrophy (-)
STATIC • Hyperpigment (-) - Hemithoraks • Hyperpigment (-) - Hemithoraks
D=S, ICS Normal, D=S, ICS Normal,
• Spider nevus (-) - Diameter AP < • Spider nevus (-) - Diameter
LL AP < LL
-Chest expansion D=S - Accessory -Chest expansion D=S - Accessory
muscle use (-) muscle use (-)
DYNAMIC -Abdominothorakal breathing (+) - IC retraction -Abdominothorakal breathing (+) - IC retraction
(-) (-)
- Palpable pain (-) - Widening - Palpable pain(-) - Widening
of ICS (-) of ICS (-)
-Tumor (-) - Tactile -Tumor (-) - Tactile
fremitus D=S fremitus D=S

Interpreta
- Sonor - Sonor
tion
- Vesicular (+) - Ronchi - Vesicular (+) • Normal
- Ronchi (-)
(+) - Whezzing (-) - Sterm
THORAX-CARDIAC EXAM 24 - 19
10

• Ictus cordis (-)

• Ictus cordis is palpable (-)

• Thrill (-)
• Epigastric pulse (-)
• Parasternal pulse (-)
• Sternal lift (-)

• Upper borderline of heart : ICS II left sternal line

• Waist of heart : ICS III left parasternal line
• Lower right borderline of heart : ICS V right sternalis line
• Lower left borderline of heart : ICS V 1-2 cm medial mid clavicularis sinistra
Interpreta
tion
Normal
 THORAX-CARDIAC EXAM 24 - 19
10

Aorta valve : S1 & S2 standart,

additional sound (-)

Pulmonary valve :
S1 & S2 standart,
additional sound (-)

Pulmonary valve :
S1 & S2 standart,
additional sound (-)

Pulmonary valve : Interpreta

S1 & S2 standart, tion
additional sound (-) Normal
 24 - 19
ABDOMEN EXAM 10

TYPE OF EXAMINATION RESULTS

Skin
• Scars (-)
• Striae (-)
• Dilated veins (-)
Spider angioma (-)
• Rashes and lesions (-)
• Caput Medusa (-)
Umbulicus Bulging (-)
Contour Round, Enlarge RUQ, Asymmetric,
Peristaltic (-) Unseen

Bowel sounds 7x/m, click and gurgle (-), metallic sound (-), bruit (-)
Lapang abdomen Timpanic
Hepar Hepar dextra 14 cm and sinistra 9 cm
Traube's space Timpanic (+)
Asites Shifting dullness (-)
 24 - 19
ABDOMEN EXAM 10

TYPE OF EXAMINATION RESULTS

Light Muscular defence (-), pain (-), distended stomach (-)

Deep Pain on right quadran (+) , visceral organ not palpable

Hepar Margo is sharp, flat surface, hard palpable, size of

hepar enlarge ( 3 cm under arcus costa)
PERMUKAAN TIDAK RATA
TEPI TUMPUL
KONSISTENSI KERAS
NYERI TEKAN (-)
PEMBESARAN (+)

Normal
Suffner (Lien)
Pain on right
Ren -
Mc. Burny and Contra - Interpretation
Murph sign • Pain on right upper quadran (+)
• Hepatoegali
 24 - 19
EXTREMITIES 10

EXAMINATION SUPERIOR INFERIOR

OEDEM -/- -/-

Akran dingin -/- -/-

Refleks Patologi -/- -/-

Refleks Fisiologi +/+ +/+

Ikterik -/- -/-

INTERPRETATION NORMAL NORMAL

Interpreta
tion
Normal
 ADDITIONAL
EXAMINATION
 23 - 19
LABORATORY TEST 10

HEMATOLOGI : DARAH RUTIN 1 HASIL 19-2-18 NILAI RUJUKAN SATUAN KETERANGAN

HEMOGLOBIN 14.3 11.7 – 15.5 g/dl N
HEMATOKRIT 42.8 33 - 45 % N
LEUKOSIT 9.49 3.6 – 11.0 Ribu/uL N
TROMBOSIT 277 150 - 440 Ribu/uL N
GOLONGAN DARAH/Rh O/Positif

Interpreta
tion
• normal
 LABORATORY TEST 23 - 19
10
KIMIA DARAH HASIL 23-10-19 NILAI RUJUKAN SATUAN KETERANGAN
Ureum 29 10 - 50 mg/dl
Creatinin Darah 0.99 0.7 – 1.3 mg/dl
Bilirubin Total 1.46 0.1 – 1.0 mg/dl H
Bilirubin Direk-Indirek
Bilirubin Direk 0.8 0 – 0.2 mg/dl H
Bilirubin Indirek 0.66 0 – 0.75 mg/dl

Total Protein 6.54 6.0 – 8.0 g/dl

Albumin-Globulin Interpreta
Albumin 2.85 3.4 – 4.8 g/dl L
Globulin 3.69 g/dl tion
SGOT 346 0 – 50 U/I H
• Hiperbilirubinemia
SGPT 97 0 – 50 U/I H
• SGOT, SGPT ↑
Natrium 134.5 135 – 147 mmol/L L • Hipoalbuminemia
Kalsium 3.75 3.5 – 5 mmol/L • Hiponatremia
Chloride 101.2 95 - 105 mmol/L
 19 - 18
USG ABDOMEN 02

Hepar : hepatomegaly with

Lien & ren : Normal
hiperechoic soliter nodul in
dextra lobe size 7.1x6.6
 19 - 18
USG ABDOMEN 02

Gallblader and pancreas :

Normal VU & prostat : Normal
 ABNORMALITAS DATA
ANAMNESIS PYSHICAL EXAM LAB EXAM USG ABDOMEN

1. Abdominal pain 11. BMI 17,2 20. hepatomegaly with

14. Total bilirubin 1.46
2. Bloated (underweigh) hiperechoic soliter
15. Direct bilirubin 0.8
3. Discomfort 12. Pain on right upper nodul in dextra lobe
16. SGOT 346
4. Weakness quadran size 7.1x6.6
17. SGPT 97
5. Fatigue 13. Hepatomegaly
18. Albumin 2.85
6. Dizziness
19. Natrium 134.5
7. Nausea
8. Vomiting
9. Loss of appetide
10. Drastic weigh loss
 HEPATOMA
PROBLEM LIST
1. Abdominal pain
2. Bloated
3. Discomfort
4. Weakness
5. Fatigue
6. Dizziness HIPOABUMIN HIPONATREMA
7. Nausea
8. Vomiting
9. Loss of appetide
10. Drastic weigh loss
11. BMI 17,2 (underweigh)
Albumin 2.85 Natrium 134.5
11, 17
12. Pain on right upper quadran
13. Hepatomegaly
14. Total bilirubin 1.46
15. Direct bilirubin 0.8
16. SGOT 346
17. SGPT 97
18. Albumin 2.85 UNDERWEIGHT
19. Natrium 134.5
20. hepatomegaly with
hiperechoic soliter nodul in
dextra lobe size 7.1x6.6
BMI
11,17.2
17
 HEPATOMA
ASSESSMENT IP Dx IP Tx
- TNM,BCLC
- Etiologic : - AFP (alfa feto protein)
Primer : HBV, - to know ca prostat : PSA (prostat spesific antigen)
HCV
- To know breast cancer : CA15-3 Curcuma 3x1
Marker Hepatitis: Hepatitis A  IgM /IgG anti HAV Lansopazole 2x1
Sekunder : lung Infeksi virus akut (IgM), Riwayat Hep.A (IgG)
cancer H.B  HbsAg, HbeAg, HBV DNA Sucralfat 3x1 C
Female : breast Reseksi tumor
H. C  IgM anti HCV
cancer
Male : ca prostat H.C kronik fase proliferasi  Anti HCV RNA kualitatif
- Faktor resiko : H. Kronik Fase proliferasi & Fase infeksius  HbeAg
Sirosis CT scan
Alkohol BIOPSI
Chest X ray ( to know metas in lung) IP Ex
Penyakit hati
autoimun
IP Mx
Penyakit hati - General status
metabolik - • Give the information
Vital sign
(hemokromatosis, about the disease and its
- Staging
defisiensi alfa-1- prognosis
antitripsin, penyakit - Complications : ensefalopati hepatikum (sign :
Wilson) hipersomnia atau insomnia), Metastasis
-Staging - Faktor predisposisi : infeksi, overdosis obat,
-metastatis pendarahan GI, konstipasi, gangguan elektrolit.
 HIPOALBUMIN IP Tx
Non Pharmacology :
- Diet high protein 1,5
ASSESSMENT gr/kgBB/day
IP Dx
Pharmacology :
- Albumin Correction :
(Albumin target – Albumin actual)xBBx
0,8 = (3,5 - 2,85) x 48 x 0,8 = 24,96
• - gram

Infus albumin 25%

100ml (1 botol)
- IP Mx IP Ex

• Albumin level
consumption high protein food
post koreksi
 HYPONATREMIA IP Tx

ASSESSMENT IP Dx

Infus NaCL 20 tpm

• -

- IP Mx IP Ex

• General
state,
Awareness, • Explain about disease
ECG, Vital
Sign
 UNDERWEIGHT IP Tx

Diet high calories

ASSESSMENT IP Dx
Underweight :
40-50 kkal/kgbb / hari  1920-2400 kkal/
hari
• - Start from 1900 – 2100 – 2300

- IP Mx IP Ex

• Body weight • Diet high calories