Case Study

Supervised by:
dr. Riki Tenggara, Sp.PD-KGEH
Presented by :
Yohanes Edwin Jonatan (2011-061-053)
Cavin Handoko (2012-061-064)
Fabiola Anastasia (2013-061-001)

Internal Medicine Department

Clerkship Period: October 2013 – January 2014
Faculty of Medicine, Atma Jaya Catholic University
 Basic information
Name : Ms. R
Age : 15 year old
Address : Jakarta
Occupation : Student
Marital status : Not married
Date of admission : August 23, 2013
Date of examination : August 23, 2013
History of Present Illness
Chief complaint :
Fever since 14 days before admission.

Additionalcomplaint :
Her body feels weak and yellowish.
History of Present Illness
• 14 days before admission, the patient complaints
cough without sputum and intermittent fever.
The fever can arise without any specific time.

• 12 days before admission, she felt her appetite

was decreased, felt nausea everytime she ate, she
felt weak, with headache, also her eyes and body
turn yellowish,
History of Present Illness
• Her stool was fluid and the colour was yellow
without any blood.
• Her urine’s colour was like a tea.
• Hours before admission, she checked herself to a
public health centre and then was sent to Atma
Jaya hospital.
History of Habit
• The patient often buy a snack with a dirty
environment.
• She seldom washes her hands before eat.
• No history using any drugs.
• No alcoholic history.
Past History
The patient never experinced this
condition before.
No history of hipertension, DM, and
allergy.
No history of blood transfusion.
 Physical Examination
General appearance: mildly ill
Consciousness: Compos Mentis, GCS = 15 (E4M6V5)
at ER: GCS = 11 (E4M6V1)
Vital signs:
Blood pressure : 110/80 mmHg
Heart rate : 80 beats per minute
Respiration rate: 24 breaths per minute
Temperature (axilla) : 36,5˚C
Body weight : 40 kg
Body height : 155 cm
Body mass index : 16,60 kg/m2
Nutritional status : underweight
 Physical Examination
Head & face: normocephali, deformity -, symmetrical face.
Eyes: no anemic conjunctiva, icteric sclera
direct pupillary responses +/+
indirect pupillary responses : +/+
round isochoric pupil , diameter 3 mm/ 3 mm
Nose: secretion -/-, no hiperemic mucosa,
no septum deviation, no deformity
Ears: normal ADS, intact tympanic membrane, secretion
-/-,
Mouth: dry lips and oral mucosa
Neck : no palpable lymph nodes, no palpable thyroid gland,
JVP 5 + 2 cm H2O
Physical Examination
Thorax
Lung:
Inspection: symmetrical chest expansion, no
retraction
Palpation : equal tactile and vocal fremitus
Percussion: resonant +/+
Lung-liver border in ICS V
Auscultation: vesicular breath sound +/+,
wheezing -/-, rhonchi -/-
 Physical Examination
Cor

I : point of maximal impulse (ictus cordis) is not seen

P : ictus cordis palpable at ICS IV left midclavicular line
P : Upper border : ICS III
Right border : ICS IV right sternal line
Left border : ICS IV midclavicular line
A : regular I & II heart sounds, no murmur, no gallop
Physical Examination
Back
• Inspection: symmetrical chest expansion
• Palpation: equal tactile and vocal fremitus, no
costovertebral angle tenderness
Percussion: resonant +/+
• Auscultation: vesicular breath sound +/+,
wheezing -/-, rhonchi -/-
Physical Examination
Abdominal
Inspection : flat
Palpation : supple, epigastric pain (+),
liver palpable 3 cm below arcus costae,
smooth surface, and elastic concistency
and spleen are not palpable, no undulation
Percussion: tympanic, shifting dullness -
Auscultation: normoactive bowel sound 4-
5x/minute
 Physical Examination
Extremity
Upper extremity
Eutrophic, normotonus, warm acral, motor
5555/5555, needle tract (-)
Physiological reflex ++/++, pathological reflex -/-
Pitting edema -/-
Lower extremity
Eutrophic, normotonus, CRT < 2 seconds, motor
5555/5555
Physiological reflex ++/++, pathological reflex -/-
Pitting edema -/-
Laboratory Studies
 Hematology : 
◦ Hemoglobin : 9,6 g/dL ↓
◦ Hematocrite : 30% ↓
◦ Leucocyte : 8.700 /uL
◦ Trombosite : 260.000 /uL
◦ ESR : 58 mm/jam
◦ Diff. Count : 0/1/2/81/12/4
 Blood Chemistry :
 Liver Function :
◦ Total protein: 6,33 g/dL
◦ Albumin : 3,3 g./dL
◦ Globulin : 3,03 g/dL
Electrolite :
◦ Natrium : 124 mmol/L ↓
◦ Kalium : 3,9 mmol/L
◦ Calsium : 1 mmol/L ↓
◦ Chlorida : 94 mmol/L ↓
 Kidney Function:
◦ Ureum : 18 mg/dL
◦ Kreatinin : 0,5 mg/dL
◦ Serum glucose : 112 mg/dL
◦ SGOT / AST: 1448 U/L ↑
◦ SGPT / ALT : 1157 U/L ↑
Laboratory Studies
Urine studies ◦ Sediment
 Eritrocyte : 2-3 /LPB
◦ Glucose : (-)
 Leukocte : 0-1 / LPB
◦ Protein : (+)  Epitel : (+)
◦ Bilirubin : (++)  Cylinder : 0-1
◦ Urobilinogen : normal  Crystal : (-)
◦ pH : 7,5  Bacteria : (-)
 Others : Fungi (+)
◦ Specific weight: 1015
◦ Occult blood : (-)
◦ Keton : (-)
◦ Nitrit : (-)
◦ Leucocyte : (-)
Laboratory Studies
 Peripheral blood smear : Anti HAV IgM (-)
anemia mikrositk hipokrom,
leukopenia (susp. Iron HbsAg (-)
deficiency anemia) Anti HCV IgM (-)
 Alkali fosfatase : 196 U/L ↑
 Gamma GT : 268 U/L ↑
Imaging Studies
Chest X-ray
◦ Suspect right bronchopenumonia, and minimal
left pleural effusion.
◦ No cardiomegaly.
USG Abdomen
◦ Non-specific hepatomegaly and splenomegaly.
No intra or extrahepatic biliary duct dilatation,
suggest liver parenkimal disease (hepatitis).
◦ Non-massive ascites.
◦ Hipovolemic gall bladder.
RESUME
Female patient 15 year old, admitted to
hospital with 14 days intermitten fever.
• 12 days before admission, she felt her appetite
was decreased, felt nausea everytime she ate, she
felt weak, with headache, also her eyes and body
turn yellowish,
• Her stool was fluid and the colour was yellow
without any blood.
• Her urine’s colour was like a tea.
RESUME
• Physical Examination :
• Normal vital sign
• Icteric Sclera
Abdominal
Inspection : flat
Palpation : supple, epigastric pain (+), liver palpable 3
cm below arcus costae, smooth surface, and elastic
concistency and spleen are not palpable, no undulation
Percussion: tympanic, shifting dullness -
Auscultation: normoactive bowel sound 4-5x/minute
Working Diagnosis
Hepatitis A.
Differential Diagnosis
Hepatitis B.
Hepatitis C.
Hemolytic Anemia.
Hepatitis Typhosa.
Treatment
Admitted to ward.
IVFD NaCl 0,9% 2000 cc/ 24 hours.
Ondancetron 2 x 8 mg IV.
Ibuprofen 2 x 400 mg PO p.r.n.
Urdahex (ursodeoxycholic acid) 2 x 250
mg PO.
Curcuma 3 x 1 tab PO.
HP Pro 3 x 7,5 mg PO.
Prognosis
Quo ad vitam : bonam
Quo ad functionam : bonam
Quo ad sanationam : bonam
THEORY
Definition
Acute viral hepatitis : a systemic infection
which primarily target the liver.
Almost all case of acute viral hepatitis
are caused by hepatitis A virus, hepatitis B
virus, hepatitis C virus, hepatitis D, or
hepatitis E virus
Epidemiology
Risk factor:
◦ Bad hygiene
◦ Crowded living place
Itspreads commonly by food or drink
contamination in the endemic area or at
the reservoir
Etiology
Hepatitis A virus (HAV)
◦ Non enveloped
◦ 27 nm
◦ RNA virus
◦ Genus hepatovirus
◦ Famili picornavirus
◦ Replication in the liver
◦ The virus live inside liver, gallblader and
faeses
Fecal oral transmission
Clinical manifestation
Incubation phase:
◦ Time when the virus attack until the symptoms
come out
◦ Phase elongation depend to the inoculums
dose which spreaded and the pathway

◦ Hepatitis A (15-45 days)

Clinical manifestation
Prodromal / pre-icteric phase :
◦ Sign can be some symptoms for eg: malaise,
myalgia, atralgia, tired, anorexia, upper
respiratory symptoms
◦ Low grade fever may occur in hepatitis A
◦ Abdominal pain often mild and continuously
stay in the upper right quadrant or epigastrium
Clinical manifestation
Icteric phase :
◦ Icterus occur after 5-10 days
◦ After icteric occur, a better clinical appearance
will happened
Clinical manifestation
Convalescent phase
◦ Begins with the disappearance of the icteric or
any other symptoms, but hepatomegaly and
liver function abnormality stay
◦ Acute condition often get better in 2-3 weeks
Patofisiologi
Diagnosis
Diagnosis of hepatitis A not only from the
clinical appereance, but also from the
serologic test
IgM anti HAV can be detected in acute
phase and 3-6 months after
Positive Anti HAV without IgM anti HAV
shows a chronic infection
Diagnosis
Diagnosis
Management
Restrict physical activity
High calorie diet
Intravenous fluid is given if vomit
happened and patient cannot accept oral
intake
Isolate the patient
 THANK YOU

REFERENCES:
 Harrison’s Principles of Internal Medicine, 18th Edition, 2012
 Buku Ajar Ilmu Penyakit Dalam, Edisi IV
 BCGuidelines.ca : Viral Hepatitis Testing (2012)
 CDC STD Treatment Guidelines 2006 : Hepatitis A.