CASE PRESENTATION

CIRRHOSIS HEPATIC

Submitted to :

Dr. Bambang P. Sp.PD

Compiled by :
1. Hani Yustikarini. B K1A 002036
2. Rahayu Tri Utami K1A 002041
3. Aida Nurwidya K1A 002045

SMF INTERNAL DISEASE SCHOOL

MEDICAL FACULTY
JENDERAL SOEDIRMAN UNIVERSITY
RSUD PROF. DR. MARGONO SOEKARJO PURWOKERTO

2008
ACKNOWLEDGEMENT

CASE PRESENTATION

CIRRHOSIS HEPATIC

Disusun oleh :
1. Hani Yustikarini. B K1A 002036
2. Rahayu Tri Utami K1A 002041
3. Aida Nurwidya K1A 002045

Have been presented at

Date, May 2008

Supervisor,

Dr. Bambang P,Sp.PD

A. PATIENT IDENTITY

Name : Mr. H
Place and date of birth : Banyumas, 17 September 1947
Occupation : Entrepreneur
Address : Gunung Lurah Rt 03/02 Cilongok-Banyumas
Sex : Male
Ethnic group : Java
Academic : Junior
Status : Married
No. CM : 672193
Entry date : 07 - 05 - 2008
Entry time : 06. 36
Exam date : 10 – 05 – 2008
Exam time : 12.00 WIB

B. ANAMNESIS (Auto and Alloanamnesis)

Take from : Soka Ward RSMS room 05

Main complaint : Enlarger stomach
Additional complaint : Vomiting, bloating and nausea, decreased appetite
: Tried and fatigue easily, swelled both leg , black feces,
Amnesia

C. PRESENT MEDICAL HISTORY

Patient arrived in internal diseases poli RSMS with company that his stomach
increasingly large during last 10 days. This large stomach in evenly and not be feel
there is bruised. Patient stated that his stomach wider to left and right side when lay
on back, that change form when lay at an angle. The complaint of increasingly larger
stomach is not along with beating heart, difficulty breathing when conducted an
activity, and wake up in the middle of night because difficult berating.
 Patient complaining his appetite was decreasing, patient confess that he
become lean during last 4 months because he only able eating in small amount.
Patient also complaining sometimes he feels nausea and painful around of upper liver
and upper left stomach part, patient rejects that he ever blood vomiting or defecate
black feces.
Patient also complaint that her body felt faint during last 4 months, mainly in
last 10 days. The faint was fells as weakness and easily fatigue when doing hard
activity. This complaint was not occurring continuously all day long. This weakness
feeling was improved when patient take a rest by sitting or beak of a while. These
complain being worsened, when patient conducting heavier activity than daily
activities, for example when patient bring his heavy commodity.
Other complaints felt by patient were both two legs were swollen since 10
days before arriving in RSMS. Initially patient feels that his legs being swollen. Both
his legs being swollen and feel heavy when walking and not disappear when patient
laying. Patient says when his leg pushed in shinbone part will leave concave marker
(indentation) and wail return to normal in 5 - 10 seconds. Patient claimed that not
fells pain in these swelling legs.

D. PAST DISEASE HISTORY

 History of hepatitis disease rejected

 History of heart disease rejected
 History of drinking drugs and herb was rejected.
 History of drinking alkohol was rejected

E. FAMILY DISEASE HISTORY

 There is no family member with same complaint with patient

 There is no family member with hepatitis disease history
 There is no family member with heart disease history
F. PHYSICAL EXAMINATION

 General condition :
moderate pain
 Consciousness
: Compos mentis
 Present bodyweight = 60
kg
 Body high = 162
cm
 Vital sign
: Blood pressure :
110/60 mmHg
Pulse : 84 x per minutes, regular
Respiration : 18 x per minutes
Temperature : 36,5 C

 Head examination :
Mesocephalic shape
: Temporal venectation (-)
Hair : Not fall easily, evenly hair distribution
Face : Skin color: dark, hyper pigmentation (+)
Eyes : Symmetric
: Anemic conjunctiva ( - / - )
: Sclera icteric ( + / + )
Nose : no breath of nose lobe
Lips : Lips not cyanosis
 Leher : JVP
not increased, no trachea deviation
 Armpit :
Alopesia pectoralis (+/+)
 Chest examination
Chest wall : no gynecomastium
no spider nevi
Lung
Inspection : simetris chest wall
No movement delay
No refraction of ribs interval
Palpation : Vokal of right and left fremitus is same.
Percussion : apex of right and left lung is sonor
Lobus medius is sonor
Lobus inferior right and left are sonor
Border of lung-hepar SIC V LMC dextra.
Auscultation : Vesicular base sound
No ronchi, no wheezing

Jantung
Inspeksi : Ictus cordis visible in SIC V 2 jari medial LMC
sinistra.
Palpation : Ictus cordis unable to lift in SIC V 2 jari
Medial LMC sinistra
Percussion : cor border
Upper right : SIC II RSB
Lower right : SIC V LSB
Upper left : SIC II LSB
Lower : SIC V 2 digit medial LMC sinistra.
Auscultation : S1 > S2, reguler
No noise, no gallop

 Abdomen examination
Inspection : convex abdominal
There is venectation
 No caput medusae
Palpation : pressure pain in epigastria
Hepar : unfelt
Lien : unfelt
Percussion : side deaf (+)
Moving deaf (+)
Undulation (+)
Auscultation : intestine noise decreased, 1 minutes 4 times with
duration of 6-8 seconds.

 Extremities examination
Superior : Edema (-/-)
No swelled finger
No cyanosis
There is many number palmar eritema with
diameter + 2-3 cm
Warm acral

Inferior : There is pitting edema at left and right pretibial

and dorsum pudis
No cyanosis
Cold Acral

G. Supporting examination
Complete blood examination
- Hb : 12 (13 – 16 g/dl)
- Ht : 20 (37 – 45 %)
- Erythrocyte : 2,28 (4 – 5 jt/ml)
- Leukocyte : 5900 (5000 – 10000 /ml)
- Trombosit : 77.000 (150.000 – 400.000 /ml)
 - MCV : 86,8 (82 – 92 pqJ)
- MCH : 29,8 (26 – 32 pqJ)
- PT : 16,5 (15,32- 17,48 sec)
- APTT : 39,3 (23,74- 32,55 sec)

Leukocyte type calculation

- Eocynophyla :1 ( 0-1 %)
- Basophyla :0 ( 1-3 %)
- Stem :0 ( 2-3 %)
- Segment : 60 ( 50-70 %)
- Lymphocyte : 38 ( 20-40 %)
- Monocyte :0 ( 2-8 %)

Blood chemical
- Total bilirubin : 22,58 (0,2-1,0 mg/dl)
- Direct Bilirubin : 18,21 (0,2 mg/dl)
- Indirect Bilirubin : 4,36 (0,2-0,8 mg/dl)
- Total Protein : 4,75 (6,0-7,8 gr/dl)
- Albumin : 3,0 (3,5-5,3 gr/dl)
- Globulin : 4,1 (2,7-3,2 gr/dl)
- Blood Ureum : 26 (10 – 50 mg/dl)
- Blood Creatinin : 1,05 (0,5 – 1,2 mg/dl)
- SGOT : 333 (<25 UI/L)
- SGPT : 158 (<25 UI/L)
- GDS : 69 (<200 mg/dl)
- Total cholesterol : 97 ( <200mg/dl)

Electrolyte
- Natrium : 143 (135-145 mmol/l)
- Kalium : 3,1 (3,5-5,5 mmol/l)
- Chloride : 103 (100-106 mmol/l)
H. SUPPORTING EXAMINATION RECOMMENDATION

 Endoscope examination

I. SUMMARY
Anamnesis :
 Enlarger stomach, feel vomiting, nausea and pain surrounding upper
liver and upper right abdominal.
 Decreased appetite, decreased bodyweight, faint body and tired
quickly
 Swelling both leg
 faint body and decreased appetite

Physical examination:
 Alopeisa
 Hyper pigmentation
 Sclera icteric
 Ginecomasty
 Unfelt hepar
 Splenomegali
 Ascites
 Venectation in abdominal wall
 Edema of pretibial and dorsum pedis

Supporting Examination
 Increase of SGOT and SGPT
 Increase birubin indirect and indirect
 Anemia
 Hipoalbumin
  Increase level of SGOT and SGPT enzyme

J. DIAGNOSIS
Cirrhosis hepatic

K. DIFFERENTIAL DIAGNOSIS
Chronic Hepatitis
L. Treatment
Non pharmacologic
 Rest: bed rest sub total
 Protein Diet and high
calories, that is 1 gr/day protein and calories 2000-3000 kkal/day
 Low salt diet 5,2 gram or 90
mol

Pharmacology
 Infuse D5% 20 drop/minutes
 Ampicillin 3 x 1 gr IV
 Spironolacton dosis 3 x100 mg
 Vit. B complex 2 x 1 tablet/day

M. PROGNOSIS
Dubia ad malam