Case Report

A 71 Years Old Male With Chief Complaint Enlarged Abdomen Back Since a Week Before Admission

By: Darma Jupriadi Tampubolon, S.Ked Julyanty Manurung, S.Ked Prof. Dr. Eddy Mart Salim, Sp.PD-KAI

Identification
Name Sex Age Address Status Occupation Religion Date of admission : Mr. U : Male : 71 Years Old : Sungai Lilin : Married : Farmer : Moslem : February 16th 2012

Chief Complaint
Enlarged abdomen back since about a week before admission

 4 month before admitted

The patient complained enlarged abdomen, its evenly distributed and not felt a bulge, the patient feels tight pants, without starting the swelling on both legs and puffy eyes in the morning, feel weak, epigastric pain and pain didnt spread to another place, nausea, blood vomit, as much as 1x/day, volume - 1 aqua glass. Blood and black faeces, as much as 3x/days, about 1 aqua glass, its like asphalt, then the patient feel more swollen legs, The patient feels no shortness of breathing, no fever, no yellow eyes and skin. Then he came to Siti Khodijah Hospital about 10 days. He get 3 blood bags transfusion, and the complaints become decrease and patient go home.

 1 month patients complained of abdominal reenlarged and taking medication from a doctor in order to reduce enlarged abdomen and eliminate swelling in both legs 1 weeks before admitted, patient complained more enlarged abdomen, epigastric pain, and pain didnt spread to another place, nausea, black vomit as much as 1x/day about aqua glass , no blood faeces, fluid faeces, and swollen legs. Then he came to RSMH and hospitalized.

History of Past Illness

Diabetic Mellitus is denied Hypertension is denied History of kidney disease is denied History of Hepatitis is denied History of blood transfusion is denied

History of Habitualy
Patient habits of drinking herbal medicine (Gendong) for two years with a frequency of once a week History of alkoholic is denied

History of Family Illness

No body in family has same illness History of hypertension in family is denied History of hepatitis in family is denied

History of Social Economic and Nutrition

Impression : enough

General Examination
General appearance : He looked severely sick Sense : Compos mentis Blood pressure : 100/70 mmHg Pulse rate : 80x/minute Respiration rate : 20 x/minute Temperature : 36,50C Body Weight : 46 kg Body Height : 170 cm BMI : 20,5 kg/m2 Abdomnal circumfrence: 88 cm

Specific Examination
Skin Skin color is black brown, normal pigmentation, eflorescense, icteric, sianotic or pale on palm and plantar (-), scar (-), hyperhidrosis (-), normal hair growth, good turgor, wet or dry in palpation (-). Lymph nodes There are no enlargement of the lymph nodes on submandibular, neck, axillaries, and inguinal.

Head Normocephaly, hair loss(-), symmetrical, alopecia (-), brittle hair (-), corn hair (-), puffy face (-), deformity (-), mallar rash (-), tenderness (-).
Eyes Exopthalmus or endopthalmus (-), pale conjungtivae palpebrae (+), icteric sclera (+), swelling of palpebra (+), good light response on both of eyes, symmetrical eyes movement, blurry vision (-).

Nose Epistaxis (-), deviated septum (-), normal mucus layer.

Ear Normal both meatus accusticus externus, decreasing hearing ability (-), tenderness mastoideus (-).
Mouth Enlargement of tonsil (-), hiperemic pharing (-).

Neck JVP (5-2) cmH2O, enlargement of thyroid glands (-). Thorax Simetric, retraction (-),Normal shape, venectasis (+), spider nevi (+).

Pulmo
Anterior I : static and dynamic: right and left lung symmetric P : right stem fremitus is same as left, crepitation (-), tenderness (-), P : sonor in right and left lung A : vesicular (+) normal in both lungs, rales (-), wheezing (-) Posterior I : static and dynamic: right and left lung symmetric P : right stem fremitus is same as left, crepitation (-), tenderness (-), P : sonor in right and left lung A : vesicular (+) normal in both lungs, rales (-), wheezing (-)

Heart
I : ictus cordis cant be seen P : ictus cordis cant be palpated P : Top border of cor is left ICS II Right border of cor is parasternal dextra line ICS 4 Left border of cor is midlavicular line ICS 5 A : HR 80 x/ minute, regular, murmur (-), gallop (-)

Abdomen
I : dome shaped (+) and tense, venectasi (+), collateral vein (+), caput medusae (-) P : tenderness (-), undulation (+), liver not palpated, spleen not palpated P : shifting dullness (+), percussion pain at left CVA (-). A : normal bowel sound

Upper extremity Pain on joint (-), pale on finger (-), erythema of palm (+), pitting edema (-), clubbing finger (-), tremor (-), chorea (-), subcutaneus nodul (-), marginatum eriteme (-), normal physiological reflex, cyanosis (-) Lower extremity Varices (-), pretibial edema (+), pain on joint (-), pale on finger (-), normal physiological reflex.

Laboratory (February 16th 2012)

Hemoglobin Eritrocyte Hematocryte Leucocyte LED Trombocyte DC MCH MVC MCHC Bil. total Bil. direk Bil. indirek : 6,5 gr% : 2.550.000 /mm3 : 21 vol% : 13.400 :68 : 247.000 : 0/2/2/72/13/7 : 21 picogram : 80 g : 31 % : 2,9 mg/dl: 1,0 mg/dl: 1,9 mg/d Uric acid Ureumia Creatinin Protein total Albumin Globulin Natrium Kalium LDH BSS HbSAg Anti HCV : 8,9 mg/dl : 59 mg/dl : 1,4 mg/dl : 5,1 g/dl : 1,9 g/dl : 3,2 g/dl : 143mmol/l : 4,7 mmol/l : 697 U/L : 128 mg/dl : (-) : (-)

Urinalysis (February 27th 2012)

Sediment:
Epitel cell Leukocyte Erytrocyte Cylinder Crystal :::::-

Protein Glucose pH

:: negative : 5,0

Abdominal USG Liver cirrosis with portal hipertension (splenomegaly)

Planning examination Repeat blood Endoscopy Benzidine test

Working Diagnosis
Hematemesis ec Liver Cirossis Decompensate + Anemic Differential Diagnosis Nehprotic Syndrome Malnutrition Dekompensate of right cardiac Hepatocellurer carsinoma

Treatment
Non Pharmacology Bed rest Liver dietary III Pharmacology IVFD D5% gtt XX/minute Asam folat 1x1 mg Propanolol 2 x 10 mg Inj. Spironolakton 3x100 gr Inj. Vit. K 3 x 1 amp iv omeprazol 1 x 20 mg Blood transfusion 300 cc

Prognostic
Quo ad vitam : Dubia ad malam Quo ad functionam : Dubia ad malam

THANK YOU

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