CIRRHOSIS HEPATIS e.

c Susp ALCOHOLIC HEPATITIS

Fathia Rachmatina 030.08.099

Anamnese
Patient was auto-anamnesed on Tuesday November 27th 2012 at 10.00 am

Patients Identity
Name Age Sex Address Occupation Religion Marital Status Race Education : Mrs. S : 45 years old : Female : Pancawati, Klari, Karawang :: Islam : Married : Sundanese : Junior High School

Chief Complaint

abdominal swelling since 2 months before admitted to hospital

Additional complaints

Nausea Dizziness Black Stool Dark urine Weakness

Picture of Patient

History of Present Ilness

Mrs. S came to the Emergency Department of Karawang State Hospital with abdominal swelling since 2 months ago before admitted to the hospital. She complained her stomache getting bigger and also complained dizziness, nausea, and weakness.

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 was black, also she had a dark urine, like tea color

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

History of past illness

Same Symptoms (+)

Hypertension

(-)

Diabetes (-)

Heart disease (-)

Liver disease (+)

Food and drug allergy (-)

Malignancy (-)

Dispepsia syndrome (-)

Family history
Same symptoms (-) Food and drug allergy (-)

Hypertension (-)

Diabetes (-)

Liver disease (-)

Heart disease (-)

Malignancy (-)

Personal and Habitual history

She consumes alcohol for 3 years She consumes traditional beverage (jamu) one time in a week

She eats at least once daily, likes fruits but no vegetables

She seldom does physical exercise

Physical Examination
General Condition Appearance : moderately ill Consciousness: compos mentis Nutritional status: 152cm,40kg Abdominal circumference: 89 cm Vital Sign
Blood pressure: 90/70 mmHg Heart rate : 68x/min Respiration rate :20 x/min Temperature : 36,5C

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

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

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 -/-

Abdominal Examination
INSPECTION
Brown skin, distended, caput medusae -

PALPATION
pain +, undulation +, liver and lien are not palpable

PERCUSSION
pain on percution -, shifting dullness +
AUSCULTATION
Bowel sound +, arterial bruit -, Venous hum -

EXTREMITIY

+ Warm acrals

Oedem

LABORATORY EXAMINATION

(November 25, 2012)

Haematology Haemoglobin Leukocyte Trombocyte Result 9,7 gr/dL 9.300 153.000 Normal Value

12-17 gr / dL 5.000 10.000 150.000 450.000

Haematocryte
Basophil Eosinophil Neutrophyls Rod Neutrophyls Segment Limphocytes Monocytes

29 %
0% 0% 2% 70 % 25 % 5%

37-48 %
0-1 % 1-3 % 2-6 % 40-70 % 20-40 % 2-8 %

Laboratory Examination
Haematology HbsAg Result Normal Value -

Blood Sugar
Ureum Creatinin Total Protein Albumin Globulin Total Bilirubin Direct Bilirubin Indirect Bilirubin

95 mg/dL
36,8 mg/dL 1,27 mg/dL 6,41 mg/dL 2,68 mg/dL 3,73 mg/dL 3,51 mg/dL 2,76 mg/dL 0,75 mg/dL

80-140 mg/Dl
10-45 mg/dL 0,4-1,5 mg/dL 6,5-8,5 mg/dL 3,5-5,0 mg/dL 2,6-3,6 mg/dL < 1,1 mg/dL < 0,6 mg/dL < 0,5 mg/dL

SGOT
SGPT

128 mg/dL
203 mg/dL

< 40 mg/dL
< 40 mg/dL

LABORATORY EXAMINATION
Urine
Colour Clarity pH Protein Bilirubin Urobilin

Result
dark like a tea Not clear 6,0 -

Abdominal USG

Description : cirrhosis hepatis and ascites

Resume
History Taking
nausea weakness 3 months before, her nails, until the whole body becomes yellow consumes alcohol for 3 years

Physical Examination
abdominal circumference : 89 cm Anemic conjuctiva +/+ icteric sclera +/+ distended abdomen, ascites pain on epigastric +, undulation + shifting dullnes +

Laboratory Examination
anemia albumin globulin total bilirubin direct bilirubin indirect bilirubin SGOT SGPT dark urin black stool

Differential Diagnosis
Cirrhosis Hepatis ec Susp Alcoholic Hepatitis

Cirrhosis Hepatis ec Drug Induced Hepatitis

Cirrhosis Hepatis ec Susp Hepatitis C

Cirrhosis Hepatis ec Alcoholic Fatty Liver

Working diagnosis

Cirrhosis Hepatis ec Susp Alcoholic Hepatitis

Suggested Examination

Liver Biopsy

Esophagoscopy

Alfa Feto Protein

Anti HcV

Protrombine time

Therapy (Medicamentosa)
Dextrose 5 % + Lasix 5 ampul 8
dpm Albumin 1 fl KSR 1X1 tab Ceftriaxon 2x1 amp Ranitidin 2x1 amp Omeprazole 1x1 amp Neurobion 1x1 tab Curcuma 3 x 1

Therapy (Non-medicamentosa)
Bed rest
Stop alcohol Stop consume jamu high protein diet

Prognosis

Ad Vitam : Dubia Ad Malam

Ad Functionam : Dubia Ad Malam

Ad Sanationam : Dubia Ad Malam