Chirrosis Hepatis e.

c
Chronic Hepatitis B
Case Report : dr. Irwin Sp.PD

 Rengasdengklok
June 4th 2012
Sundanese
Moeslem

Room
Admission
Ethnic
Religion
Last Education

D3

Marital Status

Married

Truck Driver
Saptamarga 06/03, Sinarbaya. Teluk
Jambe
52 y.o
Mr. T

Job
Address
Age
Name

IDENTITY

Main
Complai
nt

Enlarged of the
stomach since 3 month
before hospitalized

Addition
al
Complai
nt

Dyspnoe
Nausea
Oedem in both
extremities

taken on Thursday June 6th 2012

Anamnese

Picture of the patient

History of Present Disease

Present condition of the patient started 7
month ago. When he and his wife came to
RSUD Karawang for routine check up for his
DM in Internal Medicines clinic.
That moment he admitted that his legs was
swollen, he also said that his eyes and his
whole body was yellow in colour. His stomach
was little enlarged, but his wife thought that
was just ordinary bloating.
After examination he was told that he got a
liver disease (Hepatitis B) the laboratory find
that his HBsAg was positive.

After that he felt that his stomach was

enlarging more and more. He admitted that
he experienced a vomit containing blood
and his stool was containing blood too, but
only once.
He got the Hepatitis B treatment, until its
cured. He told that his body was being
skinny but the stomach kept enlarging and
both legs and hands were swollen.

Then he came again to RSUD

Karawang and diagnosed as Chirrosis
Hepatis.
He said that he has a paracintesis 3
times from February (1st),April
(2nd) , June (3rd).
From the anamnese i knew that he
was a sailor and he liked to drunk an
alcohol more than 1 bottle a day for
3 years, after that he got married

After stopped being a sailor, he

became a truck driver until now. He
admitted that he often drunk mixed
alcohol with his friends.
He also liked to drunk a traditional
drinks and sodas. And he was a
smoker for about 30 years.

DM (+)

Asthma (-)

Heart
Disease (-)

Histor
y of
Past
Diseas
e

Hypertensi
on (-)

Hepatitis B
(+)

History of Family Disease

DM (+)

Hypertensi
on (-)

Asthma (-)

Same
illness (-)

Liver
Malignanc
y (-)

Drugs consumption
Body Excercise
Tatoos

Alcohol
Smoking
Carbonated Drinks
Traditional Drinks

Habits History

General Condition
General appearance
Moderately ill
Consciousness
Compos mentis

VITAL SIGNS

Blood
Pressur
e
90/60
mmH
g

Heart
Rate
98x/
mins

Respir
ation
Rate
28x/
mins

Temper
ature
36,0
C

 Lymph gland & Thyroid gland

is not palpable
Lip: cyanosis(-)
Pharynx: hyperemic (-),
symmetrical, uvula at midline
Anemic conjunctiva +/+,
Icteric sclera -/-

Normocephali

Eyes
Mout
h
Neck
Head

Physical Examination

Thorax Examination

- Lung examination
Inspection
Palpation

: Symmetrical, retraction (-)

: Equal vocal fremitus

Percussion : Sonor
Auscultation
: Vesicular breath sound
in both lung, no ronchi and wheezing

Thorax Examination (2)

- Heart examination

Inspection : Ictus cordis seen

Palpation : Ictus cordis palpable
at 5th ICS LMCS
Percussion : right : 3rd ICS 5th ICS LSD
left: 5th ICS 1 cm medial from, LSS
above: 3rd ICS LPS
(No enlargement of the heart)
Auscultation : Regular I - II heart sound , no murmur
and gallop

ABDOMINAL EXAMINATION
Inspection
: Brown skin,distended , skin abnormality (-),
Vein dilatation (-)
Palpation
:
Sociable
Abdominal tenderness at upper right abdomen (+)
Liver not palpable
Enlargement of spleen in Schuffners Point 2.
Percussion
:
No pain present on abdominal percussion
Sounds dull
Shiffting dullness (+)
Undulation (+)
Auscultation :Bowel sound (+), arterial bruit (-), venous
hum(-)

Extremity
Examination
Warm acrals

Oedema
(Pitting oedema (+))

Extremity Examination (2)

Palmar Erytema (+)

LABORATORY FINDING
May, 22th 2012

Result

Normal

Hb

7,0

12 17 g%

Leukocyte

2800

5 10 rb

Trombocyte

178.000

150 450rb

Ht

21

37 48 %

GDS

243

80 140 mg/dl

Ureum

19.5

10 45 mg/dl

Creatinine

1.05

0,4 1,5 mg/dl

Result

Normal

HBsAg

SGOT

28

< 40 u/L

SGPT

17

< 40 u/L

Protein total

6,83

6,5 8,5 mg%

Albumin

1,98

3,5 5,0 mg%

Globulin

4,85

2,6 3,6 mg%

RESUME
Blood Test

Adjuvant Test

Anemic
Conjungtiva +/+
Tenderness at
upper right
abdomen
Enlargement of
spleen in
Schuffners Point
2.
Shiffting
dullness (+)
Undulation (+)
Palmar Erytema

Physical
Examination

Anamnese

Enlargement of
the stomach
dyspnoe,nausea
pain at upper
right abdomen,
oedem
extremities
Hepatitis B, DM
Drinking alcohol,
traditional
drinks, and
sodas.

Hb 7,0
Leukocyte 2800
Ht 21
Albumin 1,98

Globulin 4,85

Differential Diagnosis
Chirrosis
Hepatis e.c
Alcohol and DM
type 2
Chirrosis
Hepatis e.c
Chronic
Hepatitis B and
DM type 2

Working Diagnosis
Chirrosis Hepatis e.c Chronic
Hepatitis B
DM type 2

Suggested Examination

USG Abdomen
GGT
EKG
Thorax Photo

Treatment
Medicamentosa

IVFD D5 8dpm
Lasix 20 amp
Spironolacton 3x1
Aminofusin Hepar 1x1
Humalog 3x16 U
Inj. Ceftriaxon 2gr
Albumin 20 % 100cc

Non-Medicamentosa

Nutritional Therapy
Paracyntesis

Prognosis
Ad Vitam
: Dubia ad Bonam
Ad Fungtionam : Dubia ad
Malam
Ad Sanationam : Dubia ad
Malam