Hepacellular Carcinoma et causa

Hepatitis B and Low Intake

By :
Muhammad Faiz Insanul Khalis, MD

Supervisor :
M. Diana Rahim, MD

Indonesian Doctor Internship Program

Guntur Hospital Garut

October 2021
Patient Identity
Name : Mr AJ
Age : 63 years old
Gender : Male
Medical Record Number : 171713
Admission Date : October 7 2021
Time : 05.00 PM
GP : dr. Heriyandi
HISTORY TAKING
Chief complain : low intake
The patient came from dr. Melly SpPD addressed to dr. Zulkarnaen SpPD
referral from the Bethesda clinic with a diagnosis of HCC ec HBV
dehydration, low intake and fever. The patient complained of feeling a
lump in the stomach getting bigger since 5 months ago. Additional
complaints of weight loss, weakness, difficulty eating, vomiting several
times, not high fever, and had a nosebleed 1 hour before entering the ER
Guntur hospital. The black stool is shaped like a marble. One month
earlier, the patient was taken to a general practitioner by the family. GP
gave liver supplements, paracetamol, and vitamin. The doctor stated that
the patient should be referred to a internist but the patient felt he was
not ready. Shortness breath (-) and history of disease (-).

•
PHYSICAL EXAMINATION
General Condition : Looks weak
Awareness : Composmentis
GCS : 15
Blood Pressure : 100/60 mmHg
Pulse Rate : 120x/menit
Respiratory Rate : 20x/menit
Temperature : 37 C
Oxygen Saturation : 94% free air

Weight : 41 kg
Height : 162 cm
Head : mesochepal
Eyes : Anemic Conjungtiva +/+, Icteric Sclera +/+
Nose : nostring breathing ( - )

Mouth: cyanosis ( - )
Neck : lymph node enlargment ( - )
Thorax : Shape and movement are simetric, retraction (-)
Cor : S1 S2 regular, gallop (-), murmur (-)

Pulmo : Sonor and VBS in the both lung, crackles (-), wheezing (-)

Abdomen : enlarge, soepel, bowel sound ( + ) normal, epigastric and right

hypocondriac tenderness (+)

Liver : enlarge and hard

Spleen : within normal limits

Extremities :
Warm, Edema ( - ), CRT < 2 second
SUPPORTING EXAMINATION
• LABORATORY EXAMINATION RESULT (07-10-2021)
– Blood Routine: Blood Chemistry :
• Hemoglobin : 10.9 gr % Random blood sugar : 111 mg / dl
• Leucocyte : 11700/mm2 Ureum : 37 mg/dl

• Hematocrite : 32.6 % Creatinin : 0.93 mg/dl

SGOT : 258 U/L
• Thrombocyte : 541.000/mm3
SGPT : 77 U/L

– Immunology :

• Rapid antigen Covid-19 : Negative

Rontgen Thorax
DIAGNOSE
Hepacellular Carcinoma et causa Hepatitis B and
Low Intake
MANAGEMENT
• Inj asering:D5 20 tpm
• Inj Omeprazole 1x40 mg IV
• Inj ondansetron 2x4 mg IV
• PO hepamax 3x1
• PO curcuma 3x1 tab
• PO Nucral syr 3x2 cth