Division of Gastroenterology-hepatology

Department of Internal Medicine

Hasanuddin University Medical School

CASE REPORT
Hepatitis B

Division of Gastroenterology-hepatology | Department of Internal Medicine | Hasanuddin University Medical School

PATIENT IDENTITY

• Name : MUH. PUTRA YUSMIRDIANSYAH

• Date of Birth : 31 – 08 – 2003

• Gender : Male

• Address : Makassar

• Medical Report Number : 876121

HISTORY
• Chief complaint : Easily fatigue

• Present illness : 15 year old boy come to the hospital for control
with complaints of fatigue. There was no fever, no seizures, no coughing,
no tightness and no jaundice. The child is lazy to eat, defecation is normal
and brown in color, urination is normal and yellow in color. Patient has a
history of mothers with Hepatitis B since 2016. History of jaundice was
approximately 2 months ago. Hospitalized and the screening test with
reactive HBsAg result and HBV-DNA 9,6x104.
PHYSICAL EXAMINATION

• General examination : patient is in moderate pain, conscious

and cooperative (GCS15). He is in good nutritional status and
his hydration status is adequate.
Wight: 50kg, Height: 164cm.
VITAL SIGN

• Temperature : 36,8°C

• Blood pressure : 90/60mmHg

• Pulse rate : 84 beats/minute (regular rhythm)

• Respiratory rate : 20 breath/minute (vesicular)

HEAD

• Shape : Normocephal

• Face : Symmetrical left and right

• Deformity : None

• Hair : Difficult to removed

EYES
• Eksoftalmus/Enoptalmus : (-)
• Movement : Normal
• Eyelids : Edema (-)
• Conjungtiva : Anemis (-)
• Sclera : Jaundice (-)
• Cornea : Clean
• Pupil : Isokor
EARS

• Tophi : (-)

• Hearing : Normal
NOSE

• Bleeding : (-)

• Mucus : (-)
MOUTH
• Lip : Cyanosis (-), Dry (-)

• Tooth : Carieks (-)

• Gum : Bleeding (-)

• Tonsils : T1-T1 hiperemis (-)

• Farings : Hiperemis (-)

• Tounge : Dirty (-)

NECK

• Lymph node : No enlargement lymph node

• Thyroid : No enlargement thyroid

• Blood vessel : Normal

• Stiff neck : (-)

THORAX

• Inspection : Symmetrical left and right

• Palpation : Right focal fremitus is the same as left

• Percussion : Sonor

• Auscultation : Vesicular, rhonchi (-), wheezing (-)

HEART

• Inspection : No ictus cordis

• Palpation : No thrill

• Percussion : Normal

• Auscultation : Reguler
ABDOMEN

• Inspection : Flat

• Auscultation : Peristaltik (+), normal

• Palpation : Tenderness (-), massa (-), hepar and lien not

palpable

• Percussion : Tympany (+)

BACK

• Inspection : Symmetrical

• Palpation : Right focal fremitus is the same as left,

tenderness (-)

• Percussion : Sonor, flank pain (-)

• Auscultation : Vesicular, ronchi (-), wheezing (-)

EXTREMITY

• Edema (-)

• Clubbing finger (-)

• Warm hand and feet (+)

LABORATORIUM
KIDNEY FUNCTOIN NORMAL
Ureum 12 10-50mg/dL
Creatinine 0,60 <1,3mg/dL
LIVER FUNCTION
SGOT/AST 32 <38U/L
SGPT/ALT 28 <41U/L
IMMUNOSEROLOGY
Albumin 4,3 3,5-5,0gr/dL
HBeAg 0,01/Non Reactive <0,1 COI
Anti-HBe 0,02/Reactive >=0,5/Non Reactive COI

SUPPORTING EXAMINATION : Fibroscan 5,5 F0-F1

ASSESSMENT

Hepatitis B Virus Infection

PLANNING
Treatment Curliv syrup 5ml/24H/oral

Blood routine, SGOT/SGPT,

Examination plan Ureum, Creatinine, HBeAg,
Bilirubin total and direct
PROGNOSIS
Depending on the patient's condition at the time of arrival, the
presence or absence of complications and treatment
Discussion
Hepatitis B Virus
HBV : liver infection caused by the
hepatitis B virus. HBV can cause
acute and chronic liver infections.
Incubation period: 75 days
(around 30-180 days). The
hepatitis B virus can survive
outside the body for at least 7
days. During this time, the virus
can still cause infection if it enters
the body of a person who is not
protected by the vaccine. The
virus may be detected within 30 to
60 days after infection and can
persist and develop into chronic
hepatitis B.
HBV Transmission
Infected blood products :
recipient of blood products,
hemodialysis (HD) patients,
health worker, job exposure
to blood
spread by percutaneous
or mucosal exposure to
various body fluids:
saliva, menstrual,
vaginal, and seminal
fluids
Sexual transmission
Serological Markers of HBV infection
 Symptoms
Icteric phase :
• weight loss
• Sclera icteric
Konvalesens :
Acute HBV • Dark urin
• Hepatomegali (+)
physical examination :
• Abnormal liver
• Hepatomegaly
chemical examination
• tenderness in the
right quadrant area
above the abdomen

• Asymptomatic
• Acute HBV
symptoms
• liver cirrhosis
Laboratory

• HBV serological test/imunoserologi (serological markers of HBV)

• Liver biochemistry test (SGOT, SGPT, bilirubin, albumin, globumin,PT,
GGT, alkali fosfatase) ;
• USG, liver biopsy, Fibroscan
Diagnosis

Resolved Hepatitis Infection :

• History of HBV infection
• HBsAg (-)
• Serum HBV DNA is not
detected
• ALT normal
Tata Laksana
Thankyou