case dr.irwin.pptx

7/29/2019 case dr.Irwin.pptx

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CIRRHOSIS HEPATIS e.c

Susp ALCOHOLIC

HEPATITISFathia Rachmatina

030.08.099


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Anamnese

Patient was auto-anamnesed on Tuesday

November 27th 2012 at 10.00 am


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Patients Identity

Name : Mrs. S

Age : 45 years old

Sex : Female

Address : Pancawati, Klari, KarawangOccupation : -

Religion : Islam

Marital Status : Married

Race : Sundanese

Education : Junior High School


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abdominal swelling

since 2 months before

admitted to hospital

ChiefComplaint

Nausea

Dizziness Black Stool

Dark urine

Weakness

Additionalcomplaints


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Picture of Patient


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History of Present Ilness

Mrs. S came to the Emergency

Department of Karawang State Hospitalwith abdominal swelling since 2months ago before admitted to the

hospital. She complained her stomache

getting bigger and also complaineddizziness, nausea, and weakness.


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3 months before, she complained her

nails, until the whole body becomes yellow,

but this time the whole body is not yellow

anymore.

Sometimes she had a fever, and nausea

but never vomited blood. And her stool wasblack, also she had a dark urine, like tea

color


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History of treatment

She often went to the doctor at the

local clinic for her disease and was

given generic drugs She also went to an alternative

medicine and was given herbal

medicine for her symptoms

But she didnt get better


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History of past illness

Same

Symptoms

( + )

Hypertension

(-)Diabetes

(-)

Heartdisease

(-)

Liver

disease(+)

Food anddrug

allergy

(-)

Malignancy

(-)

Dispepsia

syndrome(-)


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Family history

Liver

disease(-)

Heart

disease(-)

Malignancy

(-)

Samesymptoms

(-)

Hypertension

(-)

Diabetes

(-)

Food anddrug allergy

(-)


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Personal and Habitual history

She consumesalcohol for 3 years

She consumestraditional

beverage (jamu)

one time in a week

She eats at least

once daily, likesfruits but novegetables

She seldom doesphysical exercise


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Physical Examination

General Condition

Appearance :

moderately ill Consciousness:

compos mentis

Nutritional status:

152cm,40kgAbdominal

circumference: 89 cm

Vital Sign

Blood pressure: 90/70

mmHg Heart rate :

68x/min

Respiration rate :20x/min

Temperature : 36,5C


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Black hair and evenly distributed

Anemic conjuctiva +/+ icteric sclera +/+ Direct and indirect light reflexes +/+

Normotia, ear secretion -/- hyperemic -/- tragus pain -/-

auricula pain -/- intact tymphani membrane +/+

Septum, deviation -, hyperemic concha -/- nasal discharge -/-

Red lip +, dry -, oral higiene +. Pharyngeal arc symetrical ,

tonsil T1-T1 innormal measure

Unbpalpable lymph node and thyroid, JVP 5+2 cm H2O


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Thoracal Examination-Heart

Inspection

Ictus cordis is invisible

PALPATION

Ictus cordis is palpable at 5th ICS LMCS

PERCUSSION

Right heart border : ICS III-IV LSD

Left heart border : ICS V 1 cm medial LMCS

Upper heart border : ICS III LPSS

AUSCULTATION

Reguler I-II absence of murmurs and gallop in hearts sound


15/29

Thoracal Examination-Lung

INSPECTION

Symmetrical in shape, spider navi -

PALPATION

Equal vocal fremitus

PERCUSSION

Sonor in both lungs

AUSCULTATION

Vesicular breathing sound in both lungs

ronchi -/- wheezing -/-


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Abdominal Examination

INSPECTION

Brown skin, distended, caput medusae -

PALPATION

pain +, undulation +, liver and lien are notpalpable

PERCUSSION

pain on percution -, shifting dullness +

AUSCULTATION

Bowel sound +, arterial bruit -, Venous hum -


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EXTREMITIY

+ +

+ +

Warmacrals

- -

- -

Oedem


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LABORATORY EXAMINATION

(November 25, 2012)

Haematology Result Normal Value

Haemoglobin 9,7 gr/dL 12-17 gr / dL

Leukocyte 9.300 5.000 10.000

Trombocyte 153.000 150.000 450.000

Haematocryte 29 % 37-48 %

Basophil 0 % 0-1 %

Eosinophil 0 % 1-3 %

Neutrophyls Rod 2 % 2-6 %

Neutrophyls Segment 70 % 40-70 %

Limphocytes 25 % 20-40 %

Monocytes 5 % 2-8 %


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Laboratory ExaminationHaematology Result Normal Value

HbsAg - -

Blood Sugar 95 mg/dL 80-140 mg/Dl

Ureum 36,8 mg/dL 10-45 mg/dL

Creatinin 1,27 mg/dL 0,4-1,5 mg/dL

Total Protein 6,41 mg/dL 6,5-8,5 mg/dL

Albumin 2,68 mg/dL 3,5-5,0 mg/dL

Globulin 3,73 mg/dL 2,6-3,6 mg/dL

Total Bilirubin 3,51 mg/dL < 1,1 mg/dLDirect Bilirubin 2,76 mg/dL < 0,6 mg/dL

Indirect Bilirubin 0,75 mg/dL < 0,5 mg/dL

SGOT 128 mg/dL < 40 mg/dL

SGPT 203 mg/dL < 40 mg/dL


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LABORATORY EXAMINATION

Urine Result

Colour dark like a tea

Clarity Not clear

pH 6,0

Protein -

Bilirubin -

Urobilin -


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Abdominal USG

Description :cirrhosis hepatis

and ascites


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Resume

History Taking

nausea

weakness 3 months before, her

nails, until the wholebody becomes yellow

consumes alcohol for3 years

PhysicalExamination

abdominalcircumference : 89 cm

Anemic conjuctiva +/+icteric sclera +/+

distended abdomen,ascites

pain on epigastric +,

undulation + shifting dullnes +

LaboratoryExamination

anemia albumin

globulin

total bilirubin

direct bilirubin

indirect bilirubin

SGOT SGPT dark urin

black stool


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Differential Diagnosis

Cirrhosis Hepatis ec Drug Induced Hepatitis

Cirrhosis Hepatis ec Susp Alcoholic Hepatitis

Cirrhosis Hepatis ec Alcoholic Fatty Liver

Cirrhosis Hepatis ec Susp Hepatitis C


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Working diagnosis

Cirrhosis Hepatis ec Susp

Alcoholic Hepatitis


25/29

Suggested Examination

Liver Biopsy EsophagoscopyAlfa Feto

Protein

Anti HcV

Protrombine

time


26/29

Therapy (Medicamentosa)

Dextrose 5 % + Lasix 5 ampul 8dpm

Albumin 1 fl

KSR 1X1 tab

Ceftriaxon 2x1 amp

Ranitidin 2x1 amp

Omeprazole 1x1 amp Neurobion 1x1 tab

Curcuma 3 x 1


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Therapy (Non-medicamentosa)

Bed rest

Stop alcohol

Stop consume jamu

high protein diet


28/29

Prognosis

Ad Vitam :

Dubia AdMalam

AdFunctionam :

Dubia AdMalam

AdSanationam :

Dubia AdMalam


29/29

case dr.irwin.pptx

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