TerBaru (15-09-2012) Case Report Priska Pramuji and Sugianto Mukmin

CASE REPORT
57 years old woman came to Moh. Hoesin Hospital with Chief Complaint
Enlargement of Abdomen since + 1 days before admitted to the hospital.
z
By:
Priska Pramuji, S.Ked (04114705025)
Sugianto Mukmin, S.Ked (04114708060)
Mentor:
Prof.dr.H.Eddy Mart Salim, Sp.PD, K-AI
Moderator:
Compulsory Opponent:
Apriliza Ralasati
Free Opponent:
Reni Anggraini
Arafiah Namira
Dimas Agung
Isnugraika H.Utami
Anita Revera Sari
M.Yusuf Fantoni
Nur Anisa Aulia
HernaSatria
Cynthia Lina O.
Meigi Medika
Rima Zanaria
Richard Togi Lumban Tobing
Umaimah Adilla
M.Giovanni
DEPARTEMENT OF INTERNAL MEDICINE

MOEHAMMAD HOESIN GENERAL HOSPITAL
MEDICAL FACULTY OF SRIWIJAYA UNIVERSITY
2012
CERTIFICATION PAGE
Case Report
Title
57 years old woman came to Moh. Hoesin Hospital with Chief Complaint General
Body Weakness since + 1 days before admitted to the hospital.
Written by:
Priska Pramuji, S.Ked (04114705025)
Sugianto Mukmin, S.Ked (04114708060)
Has been accepted and approved as one of the requirement in following the Senior
Register in Departement of Internal Medicine, Faculty of Medicine Sriwijaya
University Palembang, General Hospital Mohammad Hoesin Period September 3rd
November 12th
Palembang, 17th September 2012
Prof.dr.H.Eddy Mart Salim, Sp.PD, K-AI
CHAPTER I
INTRODUCTION
Cirrhosis hepatis is the final common histologic pathway for a wide variety of
chronic liver disease. It is defined as a diffuse hepatic proccess characterized by
fibrosis and the conversion of normal liver architecture into structurally abnormal
nodules. In addition to fibrosis, the complications of chirrhosis include, but are
not limited to, portal hypertension, ascites, hepatorenal syndrome, and hepatic
encephalopaty. Often poor correlation exist between histologic findings and
clinical picture. Some patient may asymptomatic and have a reasonably normal
life expectancy.
Cirrhosis takes seventh place in the world for the common cause of death. About
25.000 people death everyday because of chirrhosis. It is more common in men
than in women (1,6:1) with average age about 30-59 years old and peak of age
40-49 years old. Cirrhosis, is the terminal of hepatic fibrosis, cirrhosis takes 4,1 %
prevalence in jogjakarta and in medan 4 %. For that reason, we want to discuss
more about chirrhosis based on patient in Mohammad Hoesin.
We present a case with chief complain of abdominal enlargement which we guess
is a chirrhosis hepatis. Hope this discussion gives a lot of knowledge about
disease that have high incidence rate.
CHAPTER II
CASE REPORT
1. Identification
Name
: Miss. M
Age
: 57 years old
Sex
: Female
Address
: Tanjung Lubuk
Status
: Married
Occupation
: house wife
Religion
:ISLAM
Date of admission
: September, 6th 2012
2.Anamnesis (Autoanamnesis at September, 8th 2012)

Chief complaint: Enlargement of abdomen since + 1 days before admitted
Since + 16 days before admitted, patient complained pain in epigastrium
region, pain wasnt radiated. There was no fever. There was nausea and vomit, the
vomited material contain is the material what she ate previously, amount of vomit
was 1 glass per day, frequency of vomit was 2 times, The patient also complained
swelling of her abdomen, there was no problem with her appetite. The patient also
complained oedema both of her leg, there was no pain of her leg. There is a
problem with her urination, she said that she had tea-like urine. She had no
problem with her defecation. She takes the medication without prescription by
herself after buy the medication at hawker, she forgot the name of the medication.
Since + 1 day before admitted, patient complained general body weakness,
the weakness happened all the time, the patient still complained pain in
epigastrium, pain wasnt radiated, there wasnt fever. There was nausea, but no
vomit, The patient also complained enlargement of her abdomen, there was no
problem with her appetite. The patient also complained edema both of her leg.
There is no problem with her urination and defecation, the patient comes to
RSMH.
Previous history
Diagnose Hepatitis 1 year ago.
Drink alcohol is denied
Herbal medicine was routinely taken since 2 times a month
Hypertension history is denied
Using analgetic drug is denied
Diabetic mellitus is denied
Family history
There was no patients family who had the same complain.
3.Physical Examination
General Condition
General appearance
: She look moderately sick
Sense
: Compos mentis
Blood pressure
:110/70 mmHg
Body Weight : 50 kg
Pulse rate
: 80 x/m
Body Height : 150 cm
Temp (axilla)
: 36,9 oC
BMI
Respiration rate
: 20 x/m
: 22,2 kg/cm2
Specific Condition
Skin
Lymph nodes : There are no enlargement of the lymph nodes on
: Yellow colored, icterus (+), cyanosis (-).
submandibular, neck, axillaries and inguinal.
Head
: Normocephaly, minimal hair loss, symmetrical,
alopecia (-), brittle hair (-), puffy face (-), deformity (-),
malar rash (-).
Eyes
: Exopthalmus or endopthalmus (-), pale conjunctivae

palpebrae (+), icteric sclera (+).
Nose
: Epistaxis (-), normal nasal septum, normal mucous later.
Ear
: Normal both of meatus accusticus externus, decreasing

hearing ability (-).
Mouth
: Stomatitis (-), enlargement of tonsil (-).
Neck
: JVP (5-2) cmH2O, enlargement of lymph nodes (-),

enlargement of thyroid glands (-).
Thorax
: Symetric, retraction (-).
o Lungs
o I
: Static, dynamic, right and left lung symetric, no retraction.
o P
: Stem fremitus right = left, no widenning of intercostal

Space, no tenderness.
o P
: Sonor in both side of lungs
o A
: Vesicular (+) normal, ronchi (-), wheezing (-)
o Cor
o I
: Ictus cordis cant be seen, no vosoure cardiac
o P
:Ictus cordis cant be palpated, no thrill
o P
: Upper border: ICS II

Right border: sternal dextra line
Left border: midclavicularis sinistra line
o A
: HR 90 x/m, murmur (-), gallop (-)
Abdomen
o I
: Convex, striae(-)
o P
: Tender pain at palpation in epigastric region, hepar isnt

Palpable, lien isnt palpable.
o P
: Undulation (-), Shifting dullness (+)
o A
: Normal bowel sound
Upper and lower extremities : pretibial edema (+)
4. Laboratory Findings
7th September 2012 in RSMH
Hematology
o Hemoglobin
: 5,5 (F: 12-16 g/dl)
o Leucocyte
: 3200 (4000-10000)
moderate anemia
o Differential count
Basophil
:0
(0- 1)
Eosinophil
:1
(1- 3%)
Stem
:2
(2- 6 %)
Segment
: 47
(50- 70 %)
Lymphocyte
: 37
(20- 40 %)
Monocyte
: 13
(2- 8%)
increase
o Hematocrit
: 15
(38- 47 %)
anemia
o Trombocyte
: 163 (150-450 106 ul)
Blood Chemistry
o Total bilirubin
(<1,50 mg/dl)
o Direct bilirubin
(<1,3 mg/dl)
o Indirect bilirubin
: (0,0- 0,2 mg/dl)
o SGOT/AST
: 22
(<40 U/L)
o SGPT/ALT
: 13
(<41 U/L)
o Ureum
: 33
(15-39 mg/dl)
o Creatinine
: 1,9
(F: 0,60- 1,10 mg/dl)
o Uric Acid
: 6,9
(F: 2,6- 6,0 mg/dl)
o BSS
: 182 (<180 mg/dl)
Urinalysis
o Urobilinogen
: Normal
o Nitrit
: Negative
o Protein
: Negative
o Blood
: Negative
o Bilirubin
: Negative
o Keton
: Negative
o Glucose
: Negative
o pH
: 6,0
o Rho
: 1,020 (1,003- 1,030)
(5,0- 8,5)
o Sediment
Leucocyte
: 35-40
(0-5 FPV)
Eritrocyte
: 4-7
(0-1 FPV)
Cylinder
: Positive
(Negative)
Epithel
: Positive
(Positive)
Crystal
: Positive
(-)
Microbiology/ Faeces
o Faeces consistency
: Soft
o Colour
: Brown
o Amoeba
: Negative (Negative)
o Erytrocyte
: 0 - 1 (Negative)
o Leucocyte
: 1 2 (Negative)
o Bacteria
: Positive
o Worm egg
o Protein
o Lipid
: Positive (Negative)
o Occult Blood Test
Immunoanalyzer
o Anti HCV
: Negative
CHAPTER III
RESUME
A 57 years old women, hospitalized since 6 th September 2012 with chief
complaint general body weakness since 1 days before admitted. Since + 7 days
before admitted, patien complaine about abdominal pain in epigastrium region,
pain like-knife and persistent, There was nausea and vomit, the vomited material
contain is the material what she ate previously, The patient also complained
swelling of her abdomen, The patien also complained oedema both of her leg.
She takes the medication without prescription by herself after buy the medication
at hawker, she forgot the names of the medication. Since + 1 day before admitted,
patient complained general body weakness, the weakness happened all the time,
the patient still complained pain in epigastrium, pain like-knife and persistent.
There was nausea, The patient also complained swelling of her abdomen. The
patien also complained edema both of her leg, the patient comes to RSMH.
Hepatitis history since + 1 year ago but she doesnt routinely control, herbal
medicine routinely taken since.
From the physical examination, patient appearance is moderately sick and
compos mentis consciousness. Blood pressure 150/80 mmHg, heart rate 90
x/minutes, respiratory rate 20 x/minutes, temperature 37 oC. Eyes: pale of
conjunctiva palpebrae (+/+), icteric sclera (+/+). Abdomen: Convex, pressure pain
(+) in epigastrium region, shifting dullness (+).
Laboratory findings : Hb:6 g/dl, Ht: 19 %, total bilirubin: mg/dl, indirect
bilirubin: mg/dl, alkali fosfatase: U/l, ureum: mg/dl
CHAPTER IV
PROBLEM IDENTIFICATION AND ANALYSE
Problem Identification:
1. A 57 years old women, hospitalized since 6 th September 2012 with chief
complaint .
2.
Since + 7 days before admitted, patien complaine about abdominal pain in

epigastrium region, pain like-knife and persistent, There was nausea and
vomit, the vomited material contain is the material what she ate previously,
the amoun of vomit was 1 glass per day, the frequency of vomit was 2
times.
3. The patient complained swelling of her abdomen,

4. The patient complained edema both of her leg. She takes the medication
without prescription by herself after buy the medication at hawker, she
forgot the names of the medication.
5. Since + 1 day before admitted, patient complained general body weakness,
the weakness happened all the time, the patien still complained pain in
epigastrium, pain like-knife and persistent.
6. The patient complained swelling of her abdomen. The patien also
complained oedema both of her leg, the patient comes to RSMH.
7. Hepatitis history since + 1 year ago but she doesnt routinely control,
8. Herbal medicine routinely taken since she young.
9. Blood pressure 150/80 mmHg, heart rate 90 x/minutes, respiratory rate 20
x/minutes, temperature 37 oC. Eyes: pale of conjunctiva palpbrae (+),
icteric sclera (+). Abdomen: Convex, pressure pain (+) in epigastrium

region, shifting dullness (+).
10. Hb:6 g/dl, Ht: 19 %, total bilirubin: mg/dl, indirect bilirubin: mg/dl, alkali
fosfatase: U/l, ureum: mg/dl
Problem Analyze
1. How it the cirrhosis manifest?
2. What is the diagnosis of this patient?
3. What are the etiology of this disease?
4. How to treat this patient?
5. How is the prognosis of this patient?
Synthesis
How is the chirroshis manifest?
Usually clinical symptoms are related to portal hypertension and its sequelae, such
as
ascites,
splenomegaly,
hypersplenism,
encephalopathy,
and
bleeding
gastroesophageal varices.
Icteric manifested by an accumulation bilirubin in blood and tissue. Icteric can be
seen primary in skin, sclera and mucous membrane. Icterus manifest if bilirubin
level is above of 2,5 mg%
Hyperbilirubinemia classified by conjugated, uncojugated, and extrahepatic:
1. Hyperbilirubinemia conjugated divided into 2 (cholestasis and non
cholestasis). Cholestasis: Dubin Johnson Syndrome and Rotor Syndrome.
Non Cholestasis: Cholestasis intrahepatic, Alcohol hepatitis, Viral
Hepatitis, and Genetic
2. Cholestasis extrahepatic: Parasit infestation, Choledocholithiasis. It can be
a malignancy, example: Gallbladder cancer, Cholangiosarcoma, Pancreatic
cancer
3. Hyperbilirubinemia non conjugated: Sindrom Gilbert, Sindrom CriglerNajjar, Hemolysis
What is the diagnosis of this patient?

Based on the anamnese, physical examination and supportting examination, we
assumed that the patient get Cirrhosis hepatis
What are the etiology of this disease?

The etiology of this disease : Alcoholic, Cryptogenic, Billiaris, Cardiac,
Metabolic, Hereditary, Drug induce
Infectious disease
Bruselosis, Ekinococcus, Schistosomiasis, Toxoplasmosis, Viral Hepatitis
( hepatitis B, hepatitis C, hepatitis D, Cytomegalo virus)
Hereditary and metabolic disesase
-Antitripsin deficiency, Fanconi syndrome, Galactosemia, Gaucher disease,
Glycogen storage disease, Hemochromatosis
Drugs and Toxin
Alcohol, Amiodarone, Arsenic
Others
Cystic fibrosis, Sarcoidose
How to treat this patient?

Management is usually limited to treatment of the complications of portal
hypertension, including control of ascites, avoidance of drugs or excessive protein
intake that may induce hepatic coma, and prompt treatment of infections
To treat the cirrhosis patient the etiology of cirrhosis takes primary role to decide
the variety of treatment, we aim to reduce the progression of disease, by avoiding
the material that damage the hepar, if there is no hepatic coma
Diet:
Protein 1g/Kg BW
Calories 2000-3000 kkal/day
For the autoimmune hepatitis we can give steroid or immunosuppresive

For the hemochromatosis we can phlebotomy to reduce the iron serum level to
normal.
For the nonalcoholic liver disease, reducing body weight will prevent the
cirrhosis.
For hepatitis B, INF-, INF- and lamivudin, Lamivudin 100mg p.o for one year
For hepatitis C, Combination of Ribavirin and Interferon , Interferon 5 MIU 3
times / week for 6 months, Ribavirin 800-1000 mg/ day for 6 months
For the fibrosis, In the future the intervention of steate cell can be suppress the
fibrogenic factors, Interferon have the antifibrotic function. Kolkisin have the
antiinflammation and prevent the colagen forming. Metrotreksat and vitamin A.
How is the prognosis of this patient?
Quo ad vitam
: Dubia ad bonam
Quo ad functionam
: Dubia ad malam
Appendix
Follow up 9th September 2012
S
: Sleepless
General Appearance : Moderately Sick
Sense
: Compos Mentis
:BP
: 110/60 mmHg
RR: 30 x/m
HR
: 70x/m
T : 36,7 oC
Head

Neck
: JVP (5-2) cmH2O, enlargement of lymp nodes (-),

Thorax
o Lungs
o I
o P

o P
o A
o Cor
o I
o P
o P

o A
Abdomen
o I
: Convex, striae(-)
o P
o P
o A
Upper and lower extremities : pretibial edema (-/-)
Laboratory Findings
Hematology
o Bleeding time
: 2 menit (1-3 menit)
o Clotting time
: 8 menit (9-15 menit)
Blood Chemistry
o Total bilirubin
: 2,01 (<1,50 mg/dl)
increase
o Direct bilirubin
: 1,38 (<1,3 mg/dl)
increase
o Indirect bilirubin
: 0,63 (0,0- 0,2 mg/dl)
increase

S
: Headache
Sense
: Compos Mentis
:BP
: 110/70 mmHg
RR: 18 x/m
HR
: 68x/m
T : 36,5 oC
Head

Neck

Thorax
o Lungs
o I
: Static, dynamic, right and left lung symetric
o P
: Stem fremitus right = left
o P
o A
o Cor
o I
: Ictus cordis cant be seen
o P
:Ictus cordis cant be palpated
o P

o A
Abdomen
o I
: Convex, Striae(-)
o P
: Tenderness pain (-), hepar isnt

Palpable, Lien isnt palpable
o P
o A
: Weakness
Sense
: Compos Mentis
:BP
: 110/70 mmHg
RR: 30 x/m
HR
: 72x/m
T : 36,5 oC
Head

Neck

Thorax
o Lungs
o I
o P

o P
o A
o Cor
o I
o P
o P

o A
Abdomen
o I
: Convex, striae(-)
o P

o P
o A

S
: Headache
Sense
: Compos Mentis
:BP
: 110/70 mmHg
RR: 20 x/m
HR
: 78x/m
T : 36,5 oC
Head

Neck

Thorax
o Lungs
o I
o P

o P
o A
o Cor
o I
o P
o P

o A
Abdomen
o I
: Convex, striae(-)
o P

o P
o A
Laboratory Findings
Hematology
o Hemoglobin
: 7,5 (F: 12-16 g/dl)
moderate anemia
o Leucocyte
: 6300 (4000-10000)
o ESR
: 30 (F:15 mm/hour)
Basophil
:0
(0- 1)
Eosinophil
:2
(1- 3%)
Stem
:1
(2- 6 %)
Segment
: 56
(50- 70 %)
Lymphocyte
: 31
(20- 40 %)
Monocyte
: 10
(2- 8%)
increase
: 21
(38- 47 %)
anemia
o Hematocrit
Laboratory Findings
Hematology
o Hemoglobin
: 6,9 (F: 12-16 g/dl)
o Leucocyte
: 7500 (4000-10000)
moderate anemia
Basophil
:0
(0- 1)
Eosinophil
:1
(1- 3%)
Stem
:0
(2- 6 %)
Segment
: 68
(50- 70 %)
Lymphocyte
: 22
(20- 40 %)
Monocyte
:9
(2- 8%)
increase
: 19
(38- 47 %)
anemia
o Hematocrit
Blood Chemistry
o SGOT/AST
: 30
(<40 U/L)
o SGPT/ALT
: 16
(<41 U/L)
o Ureum
: 44
(15-39 mg/dl)
o Creatinine
: 2,0
(F: 0,60- 1,10 mg/dl)
o Uric Acid
: 6,3
(F: 2,6- 6,0 mg/dl)
Urinalysis
o xUrobilinogen
: Normal
o Nitrit
: Negative
o Protein
: Negative
o Blood
: Negative
o Bilirubin
: Negative
o Keton
: Negative
o Glucose
: Negative
o pH
: 5,5
o Berat jenis
: 1,025 (1,0005- 1,000)
(5,0- 8,5)
o Sediment
Leucocyte
: 2-3
(2-3)
Eritrocyte
: 0-1
(0-1)
Cylinder
: Negative
(Negative)
Epithel
: Positive
(Positive)
Crystal
:-
(-)
Bacteria
: Negative
(Negative)
Immunoanalyzer
o Anti HCV
: Negative
REFFERENCES
1. Bacon BR. Cirrhosis and its Complication In: Longo DL, Fauci AS,
Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrisons
Principles of Internal Medicine 18thed. New York: Mc Graw-Hill; 2012 p:.
1971-1979.
2. Price SA & Wilson LM. Disturbance of gastrointestinal system. In: Price
SA & Wilson LM. Textbook of Pathophysiology: Clinical Concepts of
Disease Process. Jakarta:EGC; 2008 p: 484.
3. Nurdjanah S. Sirosis Hati In: Sudoyo AW(ed.), Setiyohadi B(ed.), Alwi
I(ed,), Simadibrata MK(ed.), and Setiati S(ed.). Ilmu Penyakit Dalam vol 2
4th ed.Jakarta: Universitas Indonesia; 2007 p: 443-446.
4. Avunduk, Canan.Cirrhosis and its Complication In: Avunduk, Canan.

Manual
of
Gastroenterology:
Diagnosis
and
Therapy,
3rd
Ed.
Massachusetts: Lippincott Williams & Wilkins; 2002 p: (55)

5. Keshav S. Cirrhosis and chronic liver disease in: Keshav S. The
gastrointestinal system at a glance. Massachusetts: Blackwell Science Ltd;
2004 p: 94-95.
6. Guyton AC and Hall JE. Hati Sebagai suatu Organ in :Guyton AC and Hall
JE. Buku Ajar Fisologi Kedokteran edisi 11. Jakarta:EGC; 2008 p: 902907.
7. Thuvulath PJ and Maheswari A. Cirrhosis in: Thuvulath PJ and Maheswari
A.Crash Course Gastroenterology.Philadephia:Mosby Elsevier; 2006 p
143- 149.

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CASE REPORT

Anita Revera Sari

Nur Anisa Aulia

Richard Togi Lumban Tobing

DEPARTEMENT OF INTERNAL MEDICINE

Palembang, 17th September 2012

Prof.dr.H.Eddy Mart Salim, Sp.PD, K-AI

: September, 6th 2012

2.Anamnesis (Autoanamnesis at September, 8th 2012)

Diagnose Hepatitis 1 year ago.

Drink alcohol is denied

Herbal medicine was routinely taken since 2 times a month

Hypertension history is denied

Using analgetic drug is denied

Diabetic mellitus is denied

: She look moderately sick

Body Height : 150 cm

Lymph nodes : There are no enlargement of the lymph nodes on

: Yellow colored, icterus (+), cyanosis (-).

submandibular, neck, axillaries and inguinal.

: Normocephaly, minimal hair loss, symmetrical,

: Exopthalmus or endopthalmus (-), pale conjunctivae

: Epistaxis (-), normal nasal septum, normal mucous later.

: Normal both of meatus accusticus externus, decreasing

: Stomatitis (-), enlargement of tonsil (-).

: JVP (5-2) cmH2O, enlargement of lymph nodes (-),

: Symetric, retraction (-).

: Static, dynamic, right and left lung symetric, no retraction.

: Stem fremitus right = left, no widenning of intercostal

: Sonor in both side of lungs

: Vesicular (+) normal, ronchi (-), wheezing (-)

: Ictus cordis cant be seen, no vosoure cardiac

:Ictus cordis cant be palpated, no thrill

: Upper border: ICS II

: HR 90 x/m, murmur (-), gallop (-)

: Tender pain at palpation in epigastric region, hepar isnt

: Undulation (-), Shifting dullness (+)

: Normal bowel sound

Upper and lower extremities : pretibial edema (+)

: 5,5 (F: 12-16 g/dl)

: 163 (150-450 106 ul)

: (0,0- 0,2 mg/dl)

(F: 0,60- 1,10 mg/dl)

(F: 2,6- 6,0 mg/dl)

: 182 (<180 mg/dl)

: 1,020 (1,003- 1,030)

o Occult Blood Test

Since + 7 days before admitted, patien complaine about abdominal pain in

3. The patient complained swelling of her abdomen,

icteric sclera (+). Abdomen: Convex, pressure pain (+) in epigastrium

What is the diagnosis of this patient?

What are the etiology of this disease?

How to treat this patient?

For the autoimmune hepatitis we can give steroid or immunosuppresive

: Exopthalmus or endopthalmus (-), pale conjunctivae

: JVP (5-2) cmH2O, enlargement of lymp nodes (-),

: Symetric, retraction (-).

: Static, dynamic, right and left lung symetric, no retraction.

: Stem fremitus right = left, no widenning of intercostal

: Sonor in both side of lungs

: Vesicular (+) normal, ronchi (-), wheezing (-)

: Ictus cordis cant be seen, no vosoure cardiac