3. Chapter II Edit-print

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CHAPTER II

CASE REPORT

II.1 ANAMNESIS (Autoanamnesis and Alloanamnesis) on January, 21th 2013

II.1.1. Identification

Name : Mr. S

Age : 57 years old.

Sex : Male

Address : Desa Sidomulyo, Banyuasin.

Status : Married

Occupation : Rice farmer

Religion : Moslem

Admitted to hospital : Januari 10st, 2013

II.1.2. Chief Complaint

Enlargement of abdominal since 1 months before admission.

II.1.3. History of Illness

1 months before admission, the patient complained of abdomen

became larger. He also complained of abdominal fullness, no nausea, no

vomit, loss of appetite, fatigue. He denied any complain of shortness of

breath, abdominal pain, fever, swelling in palpebra superior, swelling in

both of lower extremity. His urinate and feces like usuall. He wasnt get

treated.

1 weeks before admission, the patient complained of abdomen

became larger than before. He also complained of abdominal fullness,

nausea but no vomit, loss of appetit dan fatigue. He also complained of

swelling in both of lower extremity. He denied any shortness of breath

fever and swelling in palpebra superior. His urine was tea color, his

defecation like usuall. wasnt get treated

3


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1 day before admission, the patient complained of enlargement of

abdomen became worse. He also complained of abdominal fullness,

abdominal pain, nausea but no vomit, loss of appetite, fatigue and swelling

in both of lower extremity. He denied any shortness of breath, fever and

swelling in palpebra superior. His urine was tea color, his defecation like

usual . He went to RSMH.

II.1.4. History of Past Illness

- History of having same disease was denied.

- History of blood transfusion was denied.

- History of kidney disease was denied.

- History of foaming urine was denied.

- History of jaundice was denied.

- History of hypertension was denied.

- History of diabetes mellitus was denied.

II.1.5. Family disease history

- History of having same disease in family was denied.

II.1.6. Habitual history

- History of consuming herbs since 6 years, stop 15 years ago.

- History of consuming alcohol was denied

II.2 PHYSICAL EXAMINATION (on January, 21th 2013)

A. General examination

- General condition : sick.

- Sickness condition : moderate sickness.

- Consciousness : compos mentis.

- Blood pressure : 110/70 mmHg.

- Pulse rate : 86 times/minute, regular.

- Respiration rate : 20 times/minute.

- Temperature : 36,70 C.

- Dehydration : (-)

- Body height : 165 cm


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- Body weight : 60 kg

- Weight before ascites : 55 kg

- Nutrition : IMT= 20,2 % : Normowieght

- Abdominal circumferences : 95 cm

B. Spesific examination

1. Skin

Skin color is brownish, normal pigmentation, efloresence, icteric (-),

pale on palm and plantar (-), scar (-), hyperhidrosis (-), normal hair

growth, good turgor, wet or dry in palpitation (-), nodul subcutan (-)

2. Lymph gland

There were no enlargement of the lymph nodes on submandibular,

neck, axillaries and inguinal.

3. Head

Normocephaly, symmetrical, deformity (-), alopecia (-).

4. Eye

Eksophtalmus and enophtalmus (-), edematous palpebra superior (-),

pale of conjunctiva palpebra (+/+), sclera icteric (-/-)

5. Nose

Epistaxis (-), normal nasal septum and mucous layer

6. Ear

Good hearing, normal both of meatus accusticus externus

7. Mouth

Rhagaden of lips (-), stomatitis (-), papil atrophy (-),gum bleeding (-)

8. Neck

Thyroid gland not palpable, thyroid bruit (-), jugular vein pressure (5-

2) cmH20, hypertrophy of musculus sternocleidomastoideus (-),

stiffness (-)

9. Thorax

Normal shape, symmetrical, spider naevi (+), extended intercostal

space (-), retraction (-), venectasis (-),.


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Cor

- Inspection : ictus cordis wasnt seen.- Palpation : ictus cordis wasnt palpated.

- Percussion : upper boundary of cor is ICS II, right boundary of

cor is right parasternalis line, left boundary of cor is ICS V left

midclavicularis line.

- Auscultation : heart rate 86 times/minutes, regular, murmur (-),

gallop (-).

Lung

- Inspection : static, dynamic, right and left lung are symetric

Palpation : Stem fremitus right lung = left lung

- Percussion : Sonor in both side of lungs.

- Auscultation : Vesicular (+) normal, ronchi (-), wheezing (-)

10. Abdomen

Inspection : convex, venectation (-), caput medusa (-).

Palpation : distended, liver and spleen cant palpable, tenderness (-).

Percussion : undulation (+), shifting dullness (+).

Auscultation : bowel sound (+) normal.

11. External genitalia :

Not examined

12. Upper extremity

Erythema of palm (+/+), pain on joint (-), pale on finger (-), pitting

edema (-), clubbing finger (-), tremor (-), normal physiological reflex.

13. Lower extremity

Varices (-), pretibial edema (+/+), pitting edema (+), clubbing

finger (-), pain on joint (-), pale on finger (-), normal physiological

reflex.


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II.4 ADDITIONAL EXAMINATION

Laboratory Examination

January 10th 2013

Hematology

Hemoglobin : 7,4 g/dl (N: 14-18 g/dl)

Hematocryte : 25 vol% (N: 40-48 vol%)

Leucocyte : 5.200/mm (N: 5000-10000/mm)

Trombocyte : 174.000/mm (N: 200000-500000/mm)

Diff. Count : 0/4/0/57/25/14

Immunoserology

HbsAg : +

Anti HCV : +

January 11th 2013

Blood Chemistry

Cholesterol total : 125 mg/dl (N < 200)

HDL cholesterol : 40 mg/dl (N >55 )

LDL cholesterol : 90 mg/dl (N


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Natrium : 140 mmol/I (N:135-155)

Kalium : 3,7 mmol/I (N: 3,5-5,5)

Calsium : 7,6 mmol/l (N:8,6-10,6)

Urinalysis

Sediment

- Epithel : Positive (Positive)

- Leucocyte : 1-2 (0-5 FPV)

-Eritrocyte : 5-7 (0-1 FPV)

- Cylinder : Negative

- Crystal : Negative

Bilirubin : Negative

Urobilinogen : Negative

Nitrit : Negative

Blood : Negative

Protein : Negative

Keton : Negative

Glucose : Negative

Microbiology/ Faeces

Faeces consistency : Soft

Colour : Brown

Amoeba : Negative (Negative)

Erytrocyte : 0 - 1 (Negative)

Leucocyte : 2 -3 (Negative)

Bacteria : Positive

Worm egg : Negative (Negative)

Protein : Negative (Negative)

Lipid : Positive (Negative)


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Occult Blood Test : Negative (Negative)

Abdominal Ultrasonography (January, 15

th

2013)

Interpretation : Liver shrink, hard parenchym, no mass, no cyst. Lien larger,

pankreas normal. Ascites positive.

Impression : ascites (+), leading to cirrhosis hepatis.

II.5 RESUME

Mr.S,57 y.o, with enlargement of of abdomen became worse since 1

day before admission. 1 months before admission, the patient complained of

abdomen became larger. He also complained of abdominal fullness, no

nausea, no vomit, loss of appetite, fatigue. 1 weeks before admission, the


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patient complained of abdomen became larger than before. He also

complained of abdominal fullness, nausea but no vomit, loss of appetit dan

fatigue. He also complained of swelling in both of lower extremity. 1 day

before admission, the patient complained of enlargement of abdomen became

worse. He also complained of abdominal fullness, abdominal pain, nausea but

no vomit, loss of appetite, fatigue and swelling in both of lower extremity. The

patient has habitual history of consuming herbs since 6 years, stop 15

years ago. Physical examination, moderate sickness, compos mentis. BP

110/70 mmHg, PR 86 times/minute, reguler, RR: 20 times/minute,

temperature 36,70 C, weight = 60 kg and height=152 cm, pale of conjunctiva

palpebra. In thorax examination, spider naevi (+). Abdominal is distended,

stiffness, hepar and lien are deifficult to examine, undulation. Pitting edema in

both lower extremity, pale on palmar and plantar, erythema of palmar.

Laboratory findings hemoglobin: 7.4 g/dl, hematocryte: 25 vol%, leucocyte:

5.200/mm, trombocyte: 174.000/mm, total bilirubin: 1.9 mg/dl, direct

bilirubin: 0.77 mg/dl, bilirubin indirest 1,13 mg/dL, SGOT: 55 U/L, protein

total: 6.2 g/dl, albumin: 7.4 g/dl, globulin: 5.5 g/dl, BSS: 88 mg/dl, HBs AG

positive, Anti HCV positive.

II.6 WORKING DIAGNOSIS

Cirrhosis hepatis decompensata + anemia of chronic disease

II.7 DIFFERENTIAL DIAGNOSIS

Hepatocellular carcinoma + anemia of chronic disease

Nephrotic syndrome + anemia of chronic disease

Chronic kidney disease + anemia of chronic disease

II.8 TREATMENT

Nonpharmachology

- Bedrest

- Liver diet III


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Pharmachology

- IVFD D5% gtt XX/menit (micro)

- Spironolacton 3x100mg

- Furosemide inj 2x1 amp (20 mg)

- CaCO3 inj 3x500 mg

- Lactulac syrup 3x1c

- Curcuma syr 3x1c

II.9 PLANNING

Fluid balance

Albumin correction

Transfusion of PRC 580 cc

Rontgen thorax

Prothrombine time

Aspiration of ascites

II.10 PROGNOSIS

Quo ad vitam : dubia ad bonam

Quo ad functionam : dubia ad malam

II.11 FOLLOW UP

January, 11th 2013

Mr. S had weakness. Physical examination, from vital sign was in normal

limit (sens: cm, BP: 120/70 mmHg, HR: 86 x/min, RR: 21 x/min, T: 36,50 C).

Spesific examination, we found pale of conjungtiva (+), sclera icteric (-), JVP

(5-2) cmH20. Thorax: spider naevi (+). Cor: HR 86x/min, reguler, murmur (-),

gallop (-), Pulmo: vesicular (+) normal, rales (-), wheezing (-), Abdomen: convex,

distended, liver and lien cant palpable, bowel sound (+) normal, undulation (+),


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Extremities: palmar eritema (+), pitting edema (+) on lower extremity.

Assessment was Cirrhosis hepatis decompensata + anemia of chronic disease.

Planning: Fluid balance, abdominal USG, peripheral Blood Examination (MCH,

MCV, MCHC), prothrombine time. Treatment: Bed rest, Liver diet III , IVFD

D5% gtt XX/menit (micro), Spironolacton 3x100mg, Furosemide inj 2x1 amp (20

mg), CaCO3 inj 3x500 mg, Lactulac syrup 3x1c,albumin correction, transfusion

of PRC 580 cc.

January, 12th 2013

Mr. S had weakness. Physical examination, from vital sign was in

normal limit (sens: cm, BP: 110/70 mmHg, HR: 84 x/min, RR: 20 x/min, T: 36,50

C). Spesific examination, we found pale of conjungtiva (+), sclera icteric (-), JVP




Extremities: palmar eritema (+), pitting edema (+) on lower extremity. Body

weight: 60 kg, abdominal circumferences: 94cm, fluid balance: -600 cc.

Laboratory, from hematology examination, Hemoglobin: 7,1 g/dl, Hematocryte:

24 vol%, Eritrocyte: 3.080.000/mm3, MCH : 23 pg, MCV:78 mcg, MCHC: 29%,

Reticulocyte:2,6, Leucocyte:5800/mm3, Trombocyte: 160.000/mm3, Diff count:

0/4/1/61/21/13. Peripheral Blood Examination, Eritrocyte: microcytic

hipochromic, Leucocyte: normally account and shape, Trombocyte: normally

account and shape. Impression: microcytic hipochromic anemia, caused by

chronic disease anemia.Assessment was Cirrhosis hepatis decompensata + anemia

of chronic disease. Planning: Abdominal USG, transfussion of PRC. Treatment:

Bed rest, Liver diet III, IVFD D5% gtt XX/menit (micro), Spironolacton

3x100mg, Furosemide inj 2x1 amp (20 mg), CaCO3 inj 3x500 mg, Lactulac syrup

3x1c.

January, 16th 2013


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Mr. S had shortness of breath. Physical examination, from vital sign was

increase RR (sens: cm, BP: 100/70 mmHg, HR: 89 x/min, RR: 24 x/min, T: 36,60

C). Spesific examination, we found pale of conjungtiva (+), sclera icteric (-), JVP





weight: 62 kg, abdominal circumferences : 95 cm, fluid balance: -150 cc.

Laboratory, from blood chemistry,HDL cholesterol: 26 mg/dL, Total Bilirubin:

1,9 mg/dl, Direct bilirubin: 0,77 mg/dl, Indirect bilirubin:1,13 mg/dl, SGOT: 55

U/L, Albumin: 2,2 g/dl, Globulin: 4,9 g/dl, TIBC: 128 g/dl, Fe: 19 g/dL.

Abdominal USG liver shrink, lien larger, ascites (+), leading to cirrhosis

hepatis. Assessment was Cirrhosis hepatis decompensata + anemia of chronic

disease. Planning: rontgen thorax, , transfusion of PRC. Treatment: Bed rest,

Liver diet III, IVFD D5% gtt XX/menit (micro), Spironolacton 3x100mg,

Furosemide inj 2x1 amp (20 mg), CaCO3 inj 3x500 mg, Lactulac syrup 3x1c,

Curcuma syr 3x1c, Albumin correction.

January, 19th 2013

Mr. S havent complaint, from vital sign was in normal limit (sens: cm,

BP: 110/70 mmHg, HR: 84 x/min, RR: 20 x/min, T: 36,50 C). Spesific

examination, we found pale of conjungtiva (+), sclera icteric (-), JVP (5-2)

cmH20. Thorax: spider naevi (+). Cor: HR 84x/min, reguler, murmur (-), gallop

(-), Pulmo: vesicular (+) normal, rales (-), wheezing (-), Abdomen: convex,



weight: 60 kg, abdominal circumferences : 95 cm, fluid balance: -750 cc.

Assessment was Cirrhosis hepatis decompensata + anemia of chronic disease.

Planning: rontgen thorax,transfusion of PRC, aspiration of ascites. Treatment: Bed

rest, Liver diet III, IVFD D5% gtt XX/menit (micro), Spironolacton 3x100mg,


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Furosemide inj 2x1 amp (20 mg), CaCO3 inj 3x500 mg, Lactulac syrup 3x1c,

Curcuma syr 3x1c.

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