Cirrhosis Task

Tista Ayu Fortuna

19/447931 / PFA / 01936
Diagnosis, clinical symptoms associated with
patient lab results
No. Diagnosis Clinical Symptoms
Tired easily, restlessness,
anorexia, malaise, ascites,
jaundice, variceal bleeding,
hepatic encephalopathy is a
symptom in hepatitis B patients
Chronic (Wells et al., 2015). In this
1
Hepatysis patient, symptoms were found
in the form of fatigue and
bleeding. The patient felt tired
from 11-19. For bleeding, the
patient had melena from 11-19
and had hemaptoysis on 18.
Laboratory signs and results Interpretation results Drug therapy (DRP)
Signs that can be found in hepatitis B patients An increase in SGOT / SGPT In these patients, it is better to check
are presence hepatitis surface antigen for more indicates the occurrence of HBsAg and anti-HCV to determine the
than 6 months, elevated ALT and AST, chronic hepatitis in the cause of chronic hepatitis in the patient.
hepatitis B virus DNA> 20,000 IU / ml, liver patient
biopsy results indicate the presence of chronic
hepatitis or cirrhosis (Wells et al., 2015). The
sign that can be found in this patient is an
increase in ALT AST.
SGOT: 82u / L; 103u / L
SGPT: 88u / L; 107u / L
No. Diagnosis Clinical Symptoms
Patients with hepatic cirrhosis
are sometimes asymptomatic,
hepatomegaly, ascites
splenomegaly, anorexia,
malaise, weight loss
encephalopathy, weakness,
jaundice, pruritis, GI bleeding,
coagulopathy, increased
Hepatic abdominal circumference (Wells
2 11: 11,7; 11.2
cirrhosis et al., 2015). In this case the
patient had increased abdominal
circumference, weakness and GI
bleeding.
1. Tired by the patient from 11-
19
2. melena since 11-19 and
hemaptoysis on 18.
Laboratory signs and results
Hypoalbumin, increased protombin time,
thrombocytopenia, increased SGOT SGPT
(Wells et al., 2015). These things can be found
in this case. In addition, an increase in PT can
also be a sign of cirrhosis, an increase in PT
itself is caused by a lack of vitamin K due to a
decrease in the synthetic hepatic function of
the vitamin (Koda Kimble, 2013).
SGOT: 82u / L; 103u / L
SGPT: 88u / L; 107u / L
Albumin: 2.67
PT:
12: 12,9; 11.0
13: 12,8; 11.5
16: 11,3; 11.3
18: 13,3; 10.9
Interpretation results
Increased AST, ALT and 1. The administration of aminofluid to
hypoalbumin, prolonged PT
can be a sign of hepatic
cirrhosis.
Therapy:
Aminofluid 3% 1000 ml / 24
hours (12-14)
Aminofluid 3% 500ml / 12h
(14)
Omeprazole 1x40mg (12-15)
1x30mg Lansoprazole (15-
18)
2. The choice of medication is
Drug therapy (DRP)
this patient was appropriate where
the aminofluid was an infusion
containing BCAAs. The
administration of BCAAs itself can
delay the progression ofchronic liver
injuryand can help regenerate hepatic
hepatocytes. The administration of
BCAAs has also been shown to
reduce apaptosis of hepatocyte cells
so that they can accelerate repair
ofliver injury (Tajiri and Shimizu,
2013).
inaccurate, in patients who
experience bleeding in the
gastrointestinal tract they should be
given PPIs, but when bleeding due to
portal hypertension has been
confirmed, it is better if the use of
PPIs is stopped because it can
worsen hepatic encephalopathy
(Zanetto and Guaalaupe, 2019).
Recommend discontinuation of
omeprazole and lanzoprazole as soon
as the patient is diagnosed with
portal hypertension.

No. Diagnosis Clinical Symptoms
Vomiting accompanied by blood,
black, mucus or bloody stools.
Esophageal - The patient had bleeding on the
varices pro 17th as much as 200c
3 18)
ligase (Variceal - Paien vomited 1000ml of blood
bleeding) on the 18th
- From 11-19 the patient had
black bowel movements
Laboratory signs and
Interpretation results Drug therapy (DRP)
results
Decreased hemoglobin, The primary management of bleeding patients is first
Decrease in Hb, hematocrit and platelets fluid resuscitation. NG (Nasogastric tube) placement
can be a sign of variceal must be done immediately to prevent airway
hematocrit and
bleeding. complications such as lung aspiration (Koda Kimble,
platelets 2013).
Hb: Therapy: 1. Octreotid is given to patients who experience acute
18: 8.6g / dl 1x0.25mg Somatostatin bleeding, so that the administration of somastatin in
(12-18) these patients is appropriate (Dipiro, 2015).
Low patient Tranexamic Acid 500mg / 2. Blood transfusions are given to patients who have an
hematocrit from 11- 5ml 3x1 ampoules Hb below 10g / dL (Palmer, 2007). In this patient, the
Vit K 3x10mg (12-19) patient's Hb was below 10g / dL so that the patient's
18 500cc PRC Transfusion blood transfusion was correct.
(18) 3. The administration of Vitamin K itself is intended to
The patient's Ceftriaxone 1x2gram (16- improve PT in patients with cirrhosis (Aldrich and
Rega, 2019). In this patient there was a prolonged PT,
platelets were low
on December 11, so that vitamin K administration was appropriate to
13,14,16 improve the patient's PT.
4. Tranexamic acid is a synthetic agent that has an
antifibrinolytic effect which has a lysis inhibitory action
PT:
on plasminogen so that the administration of
11: 11,7; 11.2
tranexamic acid in this patient is appropriate (Redeen,
12: 12,9; 11.0
2017).
13: 12,8; 11.5
5. The administration of ceftriaxone itself can be given
16: 11,3; 11.3
to patients who have aspiration pneumonia, in this case
18: 13,3; 10.9
the family refuses NG placement in the patient, so it is
possible that the antibiotics given are used to treat
aspiration pneumonia that may occur in patients
(Mandell et al, 2019).
No. Diagnosis Clinical Symptoms
Symptoms in patients who
experience hypovolemic
shock are patients feeling
thirsty, weak, anxious,
lightheaded, dizzy, little
urine excretion, and dark
yellow urine (Wells et al.,
2015)
Hypopholemic shock
Hypovolemic
4 experienced by these
shock
patients can be caused by
the patient losing a lot of
blood due to vomiting
blood (Koda Kimble,
2013)
In this patient, signs were
found in the form of a
patient feeling weak from
11-19.
Laboratory signs and results
1.TD 19
88/57
MAP calculations
(2x57) +88/3 = 67.3
2. 154mEq / L sodium
3. Clorida 110.5mEq / L
4. GFR 52.8
5. Srcr 1.5 mg / dL
6. Ureum: 56mg / dL
Interpretation results Drug therapy (DRP)
1. The patient's systolic The drug selection is not quite right
blood pressure <90mmHg In patients with hypovolemic shock, the initial therapy in
indicates a sign of these patients is to provide fluid therapy before giving
hypovolemic shock NE or dobutamine. The fluid therapy given to the patient
is appropriate, where the patient gets Gelofusin which is
2. Hypovolemic shock is a Coloid. Coloid is the main choice given to patients who
also characterized by an are experiencing syock hemorrhage (Koda Kimble,
increase in sodium and 2013). Dopamine can be given when the patient has been
chloride in the patient given adequate fluid resuscitation, but has not improved.
Inotropic agents such as dobutamine given to patients are
3. In patients with not an initial therapeutic option that can be given to
hypovolemic shock, there patients with hypovolemic shock (Dipiro, 2015).
may be an increase in BUN
and serum creatinine in
patients due to prerenal
renal failure.
Therapy:
1.Gelofusin loading 1500ml
2.Vascon (NE) IV 0.5mcg /
kgBW / min
3.Dobutamine IV 5mcg /
kgBW / minute
 Diagnosis /
No. Clinical Symptoms Laboratory signs and results Interpretation results Drug therapy (DRP)
medical problems

Portal hypertension can be Therapy The dose of propanolol given to patients with portal
characterized by Propanolol 1x10mg hypertension is too low. Recommend increasing the
hypervolemia, hypotension propanolol dose to 3x10mg (Widyati, 2019).
There are no specific and a decrease in systemic
Portal
5 symptoms in the patient vascular resistance (Wells et
Hypertension
with portal hypertension al., 2015). In these patients,
portal hypertension is
characterized by a decrease in
blood pressure in the patient.
Tachypnea (shallow and The presence of Treatment in ARDS patients is supportive, namely by
rapid breathing), in this tachypnea (stopping providing mechanical ventilation, prevention stress ulcer,
patient was Decreased blood pressure breathing) and a prevention of thromoembolism as well as with nutritional
characterized by (hypotension), pulse> 90x / decrease in systolic support (Saguil et al., 2012).
Acute blood pressure
shortness of breath, the minute
6 respiratory <90mmHg can be one
patient also had apnea of the signs of acute
failure TD date 19: 88 / 57mmHg
on the 18th. The patient respiratory failure.
felt shortness of breath
from 11-19 and became
heavy on the 19th.
Identify DRP problems and overcome them
 Troubleshooting and prevention
No. Medical Problems DRP type DRP
recommendations
Recommend HBsAg or anti-HCV
testing in patients to determine the
1 Chronic Hepatysis No DRP No DRP
cause of chronic hepatitis
experienced by patients.
In patients who experience bleeding in the
1. Recommend discontinuation of
gastrointestinal tract, PPIs should be given, but
omeprazole and lanzoprazole as soon
The drug when bleeding due to portal hypertension has
as the patient is diagnosed with
2 Hepatic cirrhosis selection is not been confirmed, it is best to stop using PPIs
portal hypertension.
quite right because they can worsen hepatic
2. Recommend to continue
encephalopathy (Zanetto and Guaalaupe,
administration of aminofluid
2019).
1. Recommend to continue therapy
2. Recommended monitoring of
Pro ligase
3 No DRP No DRP blood pressure, heart rate and
esophageal varices abdominal pain in patients receiving
somatostatin (Dipiro, 2015).
No. Medical DRP type DRP Troubleshooting and prevention recommendations
Problems
4. Hypovolemic The drug selection is The drug selection is not quite The fluid therapy given to the patient is appropriate, where
shock not quite right right the patient gets Gelofusin which is a Coloid. Coloid is the
In patients with hypovolemic main choice given to patients who are experiencing syock
shock, the initial therapy in these hemorrhage (Koda Kimble, 2013). Dopamine can be given
patients is to provide fluid therapy when the patient has been given adequate fluid
before giving NE or dobutamine. resuscitation, but has not improved. Inotropic agents such
as dobutamine given to patients are not an initial
therapeutic option given to hypovolemic shock patients
(Dipiro, 2015).

1. Recommend continuing gelofucine and stopping

dobutamine and Ne first.
2. Recommends monitoring of the patient's TTV, urine
output as well as the patient's mental status
3. Recommend monitoring of electrolyte levels, patient
renal function (BUN and serum creatinine) in patients.
4. Recommended PT and APTT monitoring in patients to
assess the ability of blood clotting in patients.
5. Successful fluid resuscitation is characterized by SBP>
90mmHg, CL> 2.2L / minute (Dipiro, 2015).
No. Medical Problems DRP type DRP Troubleshooting and prevention recommendations
5 Portal Hypertension The dosage is too low The dose of propanolol is 1. Recommends increasing the propanolol
inadequate for treating dosage to 3x10mg
portal hypertension in 2. Recommended monitoring of blood pressure,
patients herat rate in patients. The target heart rate in
cirrhosis patients is 55-60x / minute (Dipiro,
2015).
6 Acute respiratory No DRP No DRP 1. Recommended monitoring of oxygen
failure saturation and Pa02 in patients. Oxygen saturation
ranges from 88-95% (Saguil, 2012).
SOAP
No. Medical Subjective
Problems
In this patient, symptoms were
found in the form of fatigue and
Chronic bleeding. The patient felt tired
1 No DRP
Hepatysis from 11-19. For bleeding, the
patient had melena from 11-19
and had hemaptoysis on 18.
In this case the patient had
increased abdominal
circumference, weakness and GI
bleeding.
Hepatic
2
cirrhosis 1. Tired by the patient from 11-
19
2. melena since 11-19 and
hemaptoysis on 18.
Objective Assassment Plan
Recommend HBsAg or anti-HCV testing in patients to
SGOT: 82u / L; 103u / L determine the cause of chronic hepatitis experienced by
patients.
SGPT: 88u / L; 107u / L
SGOT: 82u / L; 103u / L
SGPT: 88u / L; 107u / L
Albumin: 2.67
PT:
11: 11,7; 11.2
12: 12,9; 11.0
13: 12,8; 11.5
Administration of
16: 11,3; 11.3
omeprazole or 1. Recommend discontinuation of omeprazole and
18: 13,3; 10.9
lanzoprazole to patients lanzoprazole as soon as the patient is diagnosed with
can exacerbate hepatic portal hypertension.
Therapy:
encephalopathy in patients 2. Recommend to continue administration of aminofluid
Aminofluid 3% 1000 ml / 24
with cirrhosis of the liver.
hours (12-14)
Aminofluid 3% 500ml / 12h
(14)
Omeprazole 1x40mg (12-15)
1x30mg of Lansoprazole
(15-18
No Medical Subjective Objective Assassment Plan
. Problems
3 Esophageal Vomiting accompanied by blood, Decrease in Hb, Therapy: 1. Recommend to continue therapy
varices pro black, mucus or bloody stools. hematocrit and platelets 1x0.25mg Somatostatin 2. Recommended monitoring of blood
ligase - The patient had bleeding on the Hb: (12-18) pressure, heart rate and abdominal pain
Tranexamic Acid 500mg in patients receiving somatostatin
(Variceal 17th as much as 200c 18: 8.6g / dl / 5ml 3x1 ampoules (Dipiro, 2015).
bleeding) - Paien vomited 1000ml of blood Vit K 3x10mg (12-19)
on the 18th Low patient hematocrit 500cc PRC Transfusion
- From 11-19 the patient had from 11-18 (18)
black bowel movements Ceftriaxone 1x2gram
The patient's platelets (16-18)
were low on December
11, 13,14,16

PT:
11: 11,7; 11.2
12: 12,9; 11.0
13: 12,8; 11.5
16: 11,3; 11.3
18: 13,3; 10.9
No. Medical Subjective Objective Assassment Plan
Problems
4 Hypovolemic In this patient, signs 1.TD 19 The drug selection is not quite right. 1. Recommend continuing gelofucine and stopping
shock were found in the form 88/57 In patients with hypovolemic shock, dobutamine and Ne first.
of a patient feeling weak MAP calculations the initial therapy in these patients is 2. Recommends monitoring of the patient's TTV, urine
from 11-19. (2x57) +88/3 = 67.3 to provide fluid therapy before giving output as well as the patient's mental status
2. 154mEq / L sodium NE or dobutamine. 3. Recommend monitoring of electrolyte levels, patient
3. Clorida 110.5mEq / L renal function (BUN and serum creatinine) in
4. GFR 52.8 patients.
4. Recommended PT and APTT monitoring in patients
5. Srcr 1.5 mg / dL
to assess the ability of blood clotting in patients.
6. Ureum: 56mg / dL 5. Successful fluid resuscitation is characterized by
SBP> 90mmHg, CL> 2.2L / minute (Dipiro, 2015).
In these patients, portal The dose of propanolol is inadequate 1. Recommends increasing the propanolol dosage to
hypertension is for treating portal hypertension in 3x10mg
Portal patients 2. Recommended monitoring of blood pressure, herat
5 There is no characterized by a
Hypertension rate in patients. The target heart rate in cirrhosis
decrease in blood
patients is 55-60x / minute (Dipiro, 2015).
pressure in the patient.
Tachypnea (shallow and There is no 1. Recommended monitoring of oxygen saturation and
rapid breathing), in this Pa02 in patients. Oxygen saturation ranges from 88-95%
patient was characterized Decreased blood (Saguil, 2012).
by shortness of breath, pressure (hypotension),
Acute
the patient also had pulse> 90x / minute
6 respiratory
apnea on the 18th. The
failure TD date 19: 88 /
patient felt shortness of
breath from 11-19 and 57mmHg
became heavy on the
19th.
References
• https://www.ncbi.nlm.nih.gov/books/NBK513297/
• Aldrich, SM and Regal, RE, 2019. Routine use of vitamin K in the treatment of cirrhosis-related coagulopathy: is it
AOK? maybe not, we say.Pharmacy and Therapeutics, 44(3), p. 131.
• Mandell, LA and Niederman, MS, 2019. Aspiration pneumonia. New England Journal of Medicine, 380(7), pp. 651-663.
• Saguil, A., Fargo, MV and Grogan, SP, 2015. Diagnosis and management of Kawasaki disease. American family
physician, 91(6), pp. 365-371.
• Palmer, K., 2007. Acute upper gastrointestinal haemorrhage. British medical bulletin, 83(1), pp. 307-324.
• Redeen, S., 2017. The trend of tranexamic use in upper gastrointestinal bleeding ulcers. Gastroenterology Research,
10(3), p. 159.
• Tajiri, K. and Shimizu, Y., 2013. Branched-chain amino acids in liver diseases. World Journal of Gastroenterology: WJG,
19(43), p. 7620.
• Zanetto, A. and Garcia-Tsao, G., 2019. Management of acute variceal hemorrhage. F1000Research, 8.
• Wells, BG, DiPiro, JT, Schwinghammer, TL, and DiPiro, CV, 2015. Pharmacotherapy Handbook.
• Alldredge, BK, Corelli, RL, Ernst, ME, Guglielmo, BJ, Jacobson, PA, Kradjan, WA and Williams, BR, 2013. Koda-
kimble and Young's applied therapeutics: the clinical use of drugs. Wolters Kluwer Health Adis (ESP).
• Child Pugh Scoring: is an assessment used to help doctors assess the severity of
disease and predict the risk and quality of life of a patient. Patients with class A child
pughs can survive for 15-20 years, while patients with child pughs above them can
only survive for 1-3 years (Koda Kimble 2013).
In patients with cirrhosis, there will be an imbalance in coagulation. This
imbalance is caused by:
1. Decreased synthesis of anticoagulant procoagulation protein by the
liver
2. Activation of coagulation factor clearance
3. Platelet disorders
4. Nutritional deficiencies
5. Fibrinolysis by dysfibrogenesis
6.Intravascular request for coagulation (DIC)
• Resuscitation using colloid alone is more effective and faster to
restore intravascular volume after acute bleeding (Koda Kimble,
2013).