CASE PRESENTATION

CIRRHOSIS HEPATIC

Submitted to :

Dr. Bambang P. Sp.PD

Compiled by :

1. Hani Yustikarini. B K1A 002036

2. Rahayu Tri Utami K1A 002041

3. Aida Nurwidya K1A 002045

SMF INTERNAL DISEASE SCHOOL MEDICAL FACULTY

JENDERAL SOEDIRMAN UNIVERSITYRSUD PROF. DR. MARGONO SOEKARJO PURWOKERTO

2008

ACKNOWLEDGEMENT

CASE PRESENTATION

CIRRHOSIS HEPATIC

Disusun oleh :

1. Hani Yustikarini. B K1A 002036

2. Rahayu Tri Utami K1A 002041

3. Aida Nurwidya K1A 002045

Have been presented at

Date, May 2008

Supervisor,

Dr. Bambang P,Sp.PD

A. PATIENT IDENTITY

Name : Mr. H

Place and date of birth : Banyumas, 17 September 1947

Occupation : Entrepreneur

Address : Gunung Lurah Rt 03/02 Cilongok-Banyumas

Sex : Male

Ethnic group : Java

Academic : Junior

Status : Married

No. CM : 672193

Entry date : 07 - 05 - 2008

Entry time : 06. 36

Exam date : 10 – 05 – 2008

Exam time : 12.00 WIB

B. ANAMNESIS (Auto and Alloanamnesis)

Take from : Soka Ward RSMS room 05

Main complaint : Enlarger stomach

Additional complaint : Vomiting, bloating and nausea, decreased appetite

: Tried and fatigue easily, swelled both leg , black feces,

Amnesia

C. PRESENT MEDICAL HISTORY

Patient arrived in internal diseases poli RSMS with company that his stomach

increasingly large during last 10 days. This large stomach in evenly and not be feel

there is bruised. Patient stated that his stomach wider to left and right side when lay

on back, that change form when lay at an angle. The complaint of increasingly larger

stomach is not along with beating heart, difficulty breathing when conducted an

activity, and wake up in the middle of night because difficult berating.

Patient complaining his appetite was decreasing, patient confess that he

become lean during last 4 months because he only able eating in small amount.

Patient also complaining sometimes he feels nausea and painful around of upper liver

and upper left stomach part, patient rejects that he ever blood vomiting or defecate

black feces.

Patient also complaint that her body felt faint during last 4 months, mainly in

last 10 days. The faint was fells as weakness and easily fatigue when doing hard

activity. This complaint was not occurring continuously all day long. This weakness

feeling was improved when patient take a rest by sitting or beak of a while. These

complain being worsened, when patient conducting heavier activity than daily

activities, for example when patient bring his heavy commodity.

Other complaints felt by patient were both two legs were swollen since 10

days before arriving in RSMS. Initially patient feels that his legs being swollen. Both

his legs being swollen and feel heavy when walking and not disappear when patient

laying. Patient says when his leg pushed in shinbone part will leave concave marker

(indentation) and wail return to normal in 5 - 10 seconds. Patient claimed that not

fells pain in these swelling legs.

D. PAST DISEASE HISTORY

History of hepatitis disease rejected

History of heart disease rejected

History of drinking drugs and herb was rejected.

History of drinking alkohol was rejected

E. FAMILY DISEASE HISTORY

There is no family member with same complaint with patient

There is no family member with hepatitis disease history

There is no family member with heart disease history

F. PHYSICAL EXAMINATION

General condition :

moderate pain

Consciousness

: Compos mentis

Present bodyweight = 60

kg

Body high = 162

cm

Vital sign

: Blood pressure :

110/60 mmHg

Pulse : 84 x per minutes, regular

Respiration : 18 x per minutes

Temperature : 36,5 C

Head examination :

Mesocephalic shape

: Temporal venectation (-)

Hair : Not fall easily, evenly hair distribution

Face : Skin color: dark, hyper pigmentation (+)

Eyes : Symmetric

: Anemic conjunctiva ( - / - )

: Sclera icteric ( + / + )

Nose : no breath of nose lobe

Lips : Lips not cyanosis

Leher : JVP

not increased, no trachea deviation

Armpit :

Alopesia pectoralis (+/+)

Chest examination

Chest wall : no gynecomastium

no spider nevi

Lung

Inspection : simetris chest wall

No movement delay

No refraction of ribs interval

Palpation : Vokal of right and left fremitus is same.

Percussion : apex of right and left lung is sonor

Lobus medius is sonor

Lobus inferior right and left are sonor

Border of lung-hepar SIC V LMC dextra.

Auscultation : Vesicular base sound

No ronchi, no wheezing

Jantung

Inspeksi : Ictus cordis visible in SIC V 2 jari medial LMC

sinistra.

Palpation : Ictus cordis unable to lift in SIC V 2 jari

Medial LMC sinistra

Percussion : cor border

Upper right : SIC II RSB

Lower right : SIC V LSB

Upper left : SIC II LSB

Lower : SIC V 2 digit medial LMC sinistra.

Auscultation : S1 > S2, reguler

No noise, no gallop

Abdomen examination

Inspection : convex abdominal

There is venectation

No caput medusae

Palpation : pressure pain in epigastria

Hepar : unfelt

Lien : unfelt

Percussion : side deaf (+)

Moving deaf (+)

Undulation (+)

Auscultation : intestine noise decreased, 1 minutes 4 times with

duration of 6-8 seconds.

Extremities examination

Superior : Edema (-/-)

No swelled finger

No cyanosis

There is many number palmar eritema with

diameter + 2-3 cm

Warm acral

Inferior : There is pitting edema at left and right pretibial

and dorsum pudis

No cyanosis

Cold Acral

G. Supporting examination

Complete blood examination

- Hb : 12 (13 – 16 g/dl)

- Ht : 20 (37 – 45 %)

- Erythrocyte : 2,28 (4 – 5 jt/ml)

- Leukocyte : 5900 (5000 – 10000 /ml)

- Trombosit : 77.000 (150.000 – 400.000 /ml)

- MCV : 86,8 (82 – 92 pqJ)

- MCH : 29,8 (26 – 32 pqJ)

- PT : 16,5 (15,32- 17,48 sec)

- APTT : 39,3 (23,74- 32,55 sec)

Leukocyte type calculation

- Eocynophyla : 1 ( 0-1 %)

- Basophyla : 0 ( 1-3 %)

- Stem : 0 ( 2-3 %)

- Segment : 60 ( 50-70 %)

- Lymphocyte : 38 ( 20-40 %)

- Monocyte : 0 ( 2-8 %)

Blood chemical

- Total bilirubin : 22,58 (0,2-1,0 mg/dl)

- Direct Bilirubin : 18,21 (0,2 mg/dl)

- Indirect Bilirubin : 4,36 (0,2-0,8 mg/dl)

- Total Protein : 4,75 (6,0-7,8 gr/dl)

- Albumin : 3,0 (3,5-5,3 gr/dl)

- Globulin : 4,1 (2,7-3,2 gr/dl)

- Blood Ureum : 26 (10 – 50 mg/dl)

- Blood Creatinin : 1,05 (0,5 – 1,2 mg/dl)

- SGOT : 333 (<25 UI/L)

- SGPT : 158 (<25 UI/L)

- GDS : 69 (<200 mg/dl)

- Total cholesterol : 97 ( <200mg/dl)

Electrolyte

- Natrium : 143 (135-145 mmol/l)

- Kalium : 3,1 (3,5-5,5 mmol/l)

- Chloride : 103 (100-106 mmol/l)

H. SUPPORTING EXAMINATION RECOMMENDATION

Endoscope examination

I. SUMMARY

Anamnesis :

Enlarger stomach, feel vomiting, nausea and pain surrounding upper

liver and upper right abdominal.

Decreased appetite, decreased bodyweight, faint body and tired

quickly

Swelling both leg

faint body and decreased appetite

Physical examination:

Alopeisa

Hyper pigmentation

Sclera icteric

Ginecomasty

Unfelt hepar

Splenomegali

Ascites

Venectation in abdominal wall

Edema of pretibial and dorsum pedis

Supporting Examination

Increase of SGOT and SGPT

Increase birubin indirect and indirect

Anemia

Hipoalbumin

Increase level of SGOT and SGPT enzyme

J. DIAGNOSIS

Cirrhosis hepatic

K. DIFFERENTIAL DIAGNOSIS

Chronic Hepatitis

L. Treatment

Non pharmacologic

Rest: bed rest sub total

Protein Diet and high

calories, that is 1 gr/day protein and calories 2000-3000 kkal/day

Low salt diet 5,2 gram or 90

mol

Pharmacology

Infuse D5% 20 drop/minutes

Ampicillin 3 x 1 gr IV

Spironolacton dosis 3 x100 mg

Vit. B complex 2 x 1 tablet/day

M. PROGNOSIS

Dubia ad malam