Sirhep Final

7/30/2019 Sirhep Final

1/23

Case Report

A 71 Years Old Male With Chief Complaint EnlargedAbdomen Back Since a Week Before Admission

By:

Darma Jupriadi Tampubolon, S.Ked

Julyanty Manurung, S.Ked

Prof. Dr. Eddy Mart Salim, Sp.PD-KAI


2/23

Identification

Name : Mr. U

Sex : Male

Age : 71 Years Old

Address : Sungai Lilin

Status : Married

Occupation : Farmer

Religion : Moslem

Date of admission : February 16th 2012


3/23

Chief Complaint

Enlarged abdomen back since about a week

before admission


4/23

4 month before admitted

The patient complained enlarged abdomen, its evenlydistributed and not felt a bulge, the patient feels tightpants, without starting the swelling on both legs andpuffy eyes in the morning, feel weak, epigastric pain

and pain didnt spread to another place, nausea, bloodvomit, as much as 1x/day, volume - 1 aqua glass.Blood and black faeces, as much as 3x/days, about -1 aqua glass, its like asphalt, then the patient feelmore swollen legs, The patient feels no shortness of

breathing, no fever, no yellow eyes and skin. Then he came to Siti Khodijah Hospital about 10 days.

He get 3 blood bags transfusion, and the complaintsbecome decrease and patient go home.


5/23

1 month patients complained of abdominal re-

enlarged and taking medication from a doctor inorder to reduce enlarged abdomen and

eliminate swelling in both legs

1 weeks before admitted, patient complained

more enlarged abdomen, epigastric pain, and

pain didnt spread to another place, nausea,

black vomit as much as 1x/day about aquaglass , no blood faeces, fluid faeces, and swollen

legs. Then he came to RSMH and hospitalized.


6/23

History of Past Illness Diabetic Mellitus is denied

Hypertension is denied History of kidney disease is denied

History of Hepatitis is denied

History of blood transfusion is denied

History of Habitualy Patient habits of drinking herbal medicine (Gendong)

for two years with a frequency of once a week

History of alkoholic is denied


7/23


8/23

General Examination

General appearance : He looked severely sick

Sense : Compos mentis

Blood pressure : 100/70 mmHg

Pulse rate : 80x/minute

Respiration rate : 20 x/minute

Temperature : 36,50C

Body Weight : 46 kg

Body Height : 170 cm BMI : 20,5 kg/m2

Abdomnal circumfrence: 88 cm


9/23

Specific Examination

Skin

Skin color is black brown, normal pigmentation,eflorescense, icteric, sianotic or pale on palm and

plantar (-), scar (-), hyperhidrosis (-), normal hairgrowth, good turgor, wet or dry in palpation (-).

Lymph nodes

There are no enlargement of the lymph nodes onsubmandibular, neck, axillaries, and inguinal.


10/23

Head

Normocephaly, hair loss(-), symmetrical, alopecia (-),

brittle hair (-), corn hair (-), puffy face (-), deformity (-),mallar rash (-), tenderness (-).

Eyes

Exopthalmus or endopthalmus (-), pale conjungtivaepalpebrae (+), icteric sclera (+), swelling of palpebra(+), good light response on both of eyes, symmetricaleyes movement, blurry vision (-).

Nose

Epistaxis (-), deviated septum (-), normal mucus layer.


11/23

Ear

Normal both meatus accusticus externus, decreasing

hearing ability (-), tenderness mastoideus (-).

Mouth

Enlargement of tonsil (-), hiperemic pharing (-).

Neck

JVP (5-2) cmH2O, enlargement of thyroid glands (-).

Thorax

Simetric, retraction (-),Normal shape, venectasis (+),spider nevi (+).


12/23

Pulmo

Anterior

I : static and dynamic: right and left lung symmetric

P : right stem fremitus is same as left, crepitation (-),

tenderness (-),

P : sonor in right and left lung A : vesicular (+) normal in both lungs, rales (-), wheezing (-)

Posterior

I : static and dynamic: right and left lung symmetric

P : right stem fremitus is same as left, crepitation (-),tenderness (-),

P : sonor in right and left lung

A : vesicular (+) normal in both lungs, rales (-), wheezing (-)


13/23

Heart

I : ictus cordis cant be seen

P : ictus cordis cant be palpated

P : Top border of cor is left ICS IIRight border of cor is parasternal dextra

line ICS 4

Left border of cor is midlavicular line ICS 5 A : HR 80 x/ minute, regular, murmur (-),

gallop (-)


14/23

Abdomen

I : dome shaped (+) and tense, venectasi

(+), collateral vein (+), caput medusae (-)

P : tenderness (-), undulation (+), liver not

palpated, spleen not palpated

P : shifting dullness (+), percussion pain at

left CVA (-).

A : normal bowel sound


15/23

Upper extremity

Pain on joint (-), pale on finger (-), erythema ofpalm (+), pitting edema (-), clubbing finger (-),

tremor (-), chorea (-), subcutaneus nodul (-),

marginatum eriteme (-), normal physiologicalreflex, cyanosis (-)

Lower extremity Varices (-), pretibial edema (+), pain on joint (-),

pale on finger (-), normal physiological reflex.


16/23

Laboratory (February 16th 2012)

Hemoglobin : 6,5 gr%

Eritrocyte : 2.550.000 /mm3

Hematocryte : 21 vol%

Leucocyte : 13.400

LED :68

Trombocyte : 247.000

DC : 0/2/2/72/13/7

MCH : 21 picogram

MVC : 80 g

MCHC : 31 %

Bil. total : 2,9 mg/dl-

Bil. direk : 1,0 mg/dl-

Bil. indirek : 1,9 mg/d

Uric acid : 8,9 mg/dl

Ureumia : 59 mg/dl

Creatinin : 1,4 mg/dl

Protein total : 5,1 g/dl

Albumin : 1,9 g/dl

Globulin : 3,2 g/dl

Natrium : 143mmol/l

Kalium : 4,7 mmol/l

LDH : 697 U/L

BSS : 128 mg/dl

HbSAg : (-)

Anti HCV : (-)


17/23

Urinalysis (February 27th 2012)

Sediment:

Epitel cell : -

Leukocyte : -

Erytrocyte : - Cylinder : -

Crystal : -

Protein : -

Glucose : negative

pH : 5,0


18/23

Abdominal USG

Liver cirrosis with portal hipertension

(splenomegaly)

Planning examination

Repeat blood

Endoscopy Benzidine test


19/23

Working Diagnosis

Hematemesis ec Liver Cirossis Decompensate

+ Anemic

Differential Diagnosis

Nehprotic Syndrome

Malnutrition

Dekompensate of right cardiac

Hepatocellurer carsinoma


20/23

Treatment

Non Pharmacology Bed rest

Liver dietary III

Pharmacology

IVFD D5% gtt XX/minute

Asam folat 1x1 mg

Propanolol 2 x 10 mg

Inj. Spironolakton 3x100 gr

Inj. Vit. K 3 x 1 amp iv omeprazol 1 x 20 mg

Blood transfusion 300 cc


21/23

Prognostic

Quo ad vitam : Dubia ad malam

Quo ad functionam : Dubia ad malam


22/23

THANK YOU


23/23

QUESTIONS

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