CASE REPORT

A 75 years old male was admitted to general hospital M. Djamil Padang with : CHIEF COMPLAINT : the abdomen became swollen since 1 month before admitted to hospital PRESENT ILLNESS HISTORY : The abdomen became swollen since 1 month before admitted to hospital. At first, the swollen as big as fistful and became bigger in 1 month Decrease of the appetite since 1 month ago Decrease of the body weight since 1 month ago. Patient and his family can not estimate how much the body weight loss. Pain in the right upper quadran since 1 month ago Black feces (+), since 1 week before admitted to hospital, 50 ml every defecate. Urine was normal Vomite (+), consist of blood, 3 days before admitted to hospital. heartburn ( - ) Lack of sleep since 3 days before admitted to hospital Never suffered yellow disease before No history of syringe use Never consume alcohol Never consume aspirin and traditional medicine like jamu PREVIOUS ILLNESS HISTORY : Had tumor on the right thight. suggested to have chemotherapy for 6 times.but only 3 times was done. tumor was operated on 2005. FAMILY ILLNESS HISTORY : none of family member has suffered illness like this SOCIAL AND ECONOMIC BACKGROUND : patient is unemployee

Physical Examination Vital Sign : General appearance Consciousness level Blood pressure Pulse rate Respiratory rate Body temperature Cyanosis General oedem Skin : Icteric Turgor Eye : Conjunctiva Sclera Head : Face Neck : Lymph node JVP Thyroid gland Thorax : Lungs : Inspection Palpation Percussion Auscultation Heart : Inspection Palpation Percussion Auscultation Abdomen : Inspection Palpation Percussion

: moderately ill : apatis : 120 / 80 : 90 /minute : 20 / minute : 37 C : (-) : (-) :: normal : anemic (+ ) : icteric () : symmetric : no enlargement : 5 - 2 cmH2O : no enlargement

: symmetric on static and dynamic state : fremitus right = left : sonor right and left : vesicular, Rh -/-, Wh -/: ictus was visible : ictus was palpable, 1 finger medial of LMCS 5th ICS, strong lift (-) : Left border = 1 finger medial of LMCS 5th ICS Right border = right sternalis line Upper border = 2nd ICS : irregular rhythm, murmur (-) : swollen abdomen, collateral ( + ) : liver was palpable 5 finger under Arcus Costarum, Nodules ( + ), pressure pain ( + ), blunt edge, hard Spleen was palpable S-6 : dull

Auscultation

: peristaltic sound was normal, bruit ( - )

Back : Knock pressure of Costo Vertebrae Angle (-) Genitalia and Anal : Haemorrhoid ( + ), black feces ( + ) Extremitas : Flapping tremor (+) Palmar eritem ( + ) Physiological reflect (+/+) Phatological reflect (-/-) Laboratory Findings Blood : Hb : 7.3 gr% Leukosit : 17.800 /mm Trombosit : 294.000 /mm Random blood glucose : 118 mg% Ureum : 38 mg % Number Connection Test : 730 Working Diagnosis : - hepatic encephalopaty grade I ec. Hematemesis melena ec. Oesophageal varices bleeding ec chirrosis hepatis post necrotic decompensated stage - metastatic liver carcinoma suspect metastases to the lung - haemorrhoid interna Differential Diagnosis : - intra abdomen tumor - primary liver carcinoma - hepatic encephalopaty grade I ec. Hematemesis melena ec. Gastrophaty erosion Therapy : -

Bed rest/fasting/NGT/liver diet I IVFD comafusin : triofusin : NaCl 0.9% 1 : 2 : ! Cefotaxim IV 2 x 1 gr Transamin 3 x 1 ampul IV Vitamin K 3 x 1 ampul IV Vitamin C 3 x 1 ampul IV Madopar 3 x 1 ampul IV Laxadin 3 x 1 Neurotropic 3 x 1 tab Curcuma 3 x 1 tab Spironolakton 1 x 100 mg Catheter urine Clisma

Suggested examination : - Routine blood, routine urin, routine faeces - Liver function test - Renal function test - Hepatitis marker test - USG abdomen - CT scan abdomen - Endoscopy - Rontgen thorax - Liver biopsy

Follow up February 1st 2007 A : - lack of sleep - defecate ( - ), mixturition ( - ) - cough (+) Vital sign GA moderate Lung Heart : : Stq Stq Stq flapping tremor ( + ), palmar eritem (+ ) HbsAg ( - ), Anti HCV ( - ) Hb : 8.0 mg% Leukosit : 17.800 /mm Hematokrit : 25 % Trombosit : 326.000 /mm Diff. Count : 0/1/6/77/10/6 shift to the right Blood slide : eritrosit : normokrom anisositosis Na : 142 mEq/dL K : 6.5 mEq/dL Cl : 117 mEq/dL Total protein : 5.1 g/dL Albumin : 2.21 g/dL Globulin : 2.89 g/dL SGOT : 119 SGPT : 85 Urine : LC apatis BP 110/60 PR 92 RR 22 T 36

Abdoment : Extremities : Lab. Finding:

WD / :

: protein ( - ) reduksi ( - ) sediment : leukosyt ++ eritrosyt ++ bilirubin : urobilin : + keton bodies : - anemia normokrom anisositosis ec. Hematemesis melena - hepatic encephalopaty grade I ec. Hematemesis melena ec. oesophageal varices bleeding ec chirrosis hepatis post necrotic decompensated stage - metastatic liver carcinoma suspect metastases to the lung - haemorrhoid interna : - continued - whole blood transfusion

chemical

Th/

February 2nd 2007 A : lack of sleep, restless GA moderate Lung Heart : : Stq Stq Stq Stq Stq continued LC apatis BP 110/60 PR 98 RR 22 T 35,5 Vital sign

Abdoment : Extremities : WD/ Th/ : :

February 5th 2007 A : lack of sleep, restless, cough (+)

Vital sign GA moderate Lung Heart : : Stq Stq Stq Stq : Hb Leukosit trombosit : 9.9 mg% : 19.700 /mm : 270.000 /mm LC apatis BP 110/70 PR 90 RR 18 T 36

Abdoment : Extremities : Lab. Finding

WD / : - hepatic encephalopaty grade I ec. Hematemesis melena ec. Oesophageal varices bleeding ec chirrosis hepatis post necrotic decompensated stage - metastatic liver carcinoma suspect metastases to the lung - haemorrhoid interna Th/ : continued

February 7th 2007 A : - lack of sleep, cough (+)

Vital sign GA moderate Lung Heart : : Stq Stq Stq flapping tremor ( + ), palmar eritem (+ ) : Na K Cl Total protein Albumin : 127 mEq/dL : 4.6 mEq/dL : 91mEq/dL : 5.3 g/dL : 2.17 g/dL LC apatis BP 110/60 PR 90 RR 22 T 36

Abdoment : Extremities : Lab. Finding

Globulin SGOT SGPT WD / :

: 3.13 g/dL : 23 : 18

- hepatic encephalopaty grade I ec. Hematemesis melena ec. Oesophageal varices bleeding ec chirrosis hepatis post necrotic decompensated stage - metastatic liver carcinoma suspect metastases to the lung - haemorrhoid interna - hiponatremi ec. low intake

February 10th 2007 Vital sign GA moderate Lung Heart : : LC soporous BP 110/60 PR 96 RR 20 T af

Stq Stq Stq flapping tremor ( - ), palmar eritem (+ ) : Na K Cl Total protein Albumin Globulin SGOT SGPT : 121 mEq/dL : 4.0 mEq/dL : 92 mEq/dL : 7.5 g/dL : 3.48 g/dL : 4.02 g/dL : 234 : 138

Abdoment : Extremities : Lab. Finding

WD / : - hepatic encephalopaty grade IV ec. Hematemesis melena ec. Oesophageal varices bleeding ec chirrosis hepatis post necrotic decompensated stage - metastatic liver carcinoma suspect metastases to the lung - haemorrhoid interna - hiponatremi ec. low intake February 13th 2007 USG abdomen : Metastatic liver carcinoma metastases to nodes ec? DISCUSSION A 75 years old male was admitted to department of internal medicine general hospital Dr. M. Djamil Padang on January 31th 2007 with diagnosis :

- hepatic encephalopaty grade I ec. Hematemesis melena ec. Oesophageal varices bleeding ec chirrosis hepatis post necrotic decompensated stage - metastatic liver carcinoma suspect metastases to the lung - haemorrhoid interna The diagnosis of this case made based on anamnesis, physical examination, and laboratory findings. From anamnesis we found swollen abdomen that became bigger in 1 month, decrease of the appetite and body weight, pain in right upper quadran of the abdomen, and history of tumor on the tight that had been operate and got chemotherapy. There also cough, black feces, vomite that consist of blood, and lack of sleep. From physical examination we found swollen abdomen, hepatosplenomegaly, collateral vein, flapping tremor, palmar eritem, haemorrhoid and black feces. Number connection test result is 7 minutes 30 secons. From laboratory findings we found the increase of SGOT and SGPT, and reverse of albumin-globulin ratio. Treatment of this patient are : Bed rest/fasting/NGT/liver diet I IVFD comafusin : triofusin : NaCl 0.9% 1 : 2 : ! Cefotaxim IV 2 x 1 gr Transamin 3 x 1 ampul IV Vitamin K 3 x 1 ampul IV Vitamin C 3 x 1 ampul IV Madopar 3 x 1 ampul IV Laxadin 3 x 1 Neurotropic 3 x 1 tab Curcuma 3 x 1 tab Spironolakton 1 x 100 mg Catheter urine clisma

I suggest to use propanolol in this case in order to increase the portal hypertension. The drugs for cough have not given yet. I suggest ambroxol syrup to choose in this case. Prognosis of this patient is dubia ad malam