CASE REPORT 57 years old woman came to Moh.

Hoesin Hospital with Chief Complaint General Body Weakness since + 1 days before admitted to the hospital.

By: Priska Pramuji, S.Ked Sugianto Mukmin, S.Ked (04114708060)

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

Moderator: Compulsory Opponent: Free Opponent:

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 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 one of the gastrointestinal diseaseas.

CHAPTER II CASE REPORT 1. Identification Name Age Sex Address Status Occupation Religion Date of admission : : : : : : : :

2.Anamnesis Chief complaint:generalized weakness since + 1 days before admitted Since + 7 days before admitted, patient complained pain in epigastrium region, pain like-knife and persistent. 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 patien also complained oedema both of her leg, there was no pain of her leg. There is no problem with her urination and 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 patien still complained pain in epigastrium, pain like-knife and persistent, pain wasnt radiated, there wasnt fever. There was nausea, but no vomit, The patient also complained swelling of her abdomen, there was no problem with her appetite. The patien 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 since 1 year ago at. Herbal medicine was routinely taken since Hypertension history 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 Sense : She look moderately sick : Compos mentis

Blood pressure Pulse rate Temp (axilla) Respiration rate

:150/80 mmHg : 90 x/m : 36,7 oC : 20 x/m

Body Weight : kg Body Height : cm BMI : ()

Specific Condition Skin : Yellow colored, icterus (+), cyanosis (-).

Lymph nodes : There are no enlargement of the lymph nodes on 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 Ear : Epistaxis (-), normal nasal septum, normal mucous later. : Normal both of meatus accusticus externus, decreasing hearing ability (-). Mouth Neck : Stomatitis (-), enlargement of tonsil (-). : JVP (5-2) cmH2O, enlargement of lymp nodes (-), enlargement of thyroid glands (-). Thorax o Lungs o I o P o P o A o Cor o I o P o P : Ictus cordis cant be seen :Ictus cordis cant be palpated : Upper border: ICS II Right border: parasternal dextra line Left border: axilaris anterior sinistra line Lower border: ICS V midclavicularis line o A : HR 90 x/m, murmur (-), gallop (-) : Static, dynamic, right and left lung symetric : Stem fremitus right = left : Sonor in both side of lungs : Vesicular (+) normal, ronchi (-), wheezing (-) : Symetric, retraction (-).

Abdomen o I o P : Convex : Tender pain at palpation in epigastric region, hepar isnt palpable o P o A : Undulation (-), Shifting dullness (+) : Normal bowel sound

Upper and lower extremities : pretibial edema (-)

4. Laboratory Findings 6th September 2012 in RSMH Hematology o Hemoglobin o Leucocyte o Differential count Basophil Eosinophil Stem Segment :0 :1 :0 : 68 (0- 1) (1- 3%) (2- 6 %) (50- 70 %) (20- 40 %) (2- 8%) (38- 47 %) increase anemia : 6,0 (F: 12-16 g/dl) : 7500 (4000-10000) moderate anemia

Lymphocyte : 22 Monocyte :9 : 19

o Hematocrit o Trombocyte

: 122 (150-450 106 ul)

Blood Chemistry

o Total bilirubin o Direct bilirubin o Indirect bilirubin o SGOT/AST o SGPT/ALT o Alkaline Fosfatase o Ureum o Creatinine o Uric Acid o BBS Urinalysis o Urobilinogen o Nitrit o Protein o Blood o Bilirubin o Keton o Glucose o pH o Berat Jenis o Sediment Leucocyte Eritrocyte Cylinder

: : : : : : : : : :

(<1,50 mg/dl) (<1,3 mg/dl) (0,0- 0,2 mg/dl) (<40 U/L) (<41 U/L) (F:<103 U/L) (15-39 mg/dl) (F: 0,60- 1,10 mg/dl) (F: 2,6- 6,0 mg/dl) (<180 mg/dl)

: Normal : Negative : Negative : Negative : Negative : Negative : Negative : 5,5 (5,0- 8,5)

: 1,025 (1,0005- 1,000)

: 2-3 : 0-1

(2-3) (0-1) (Negative)

: Negative

Epithel Crystal Bacteria

: Positive :: Negative

(Positive) (-) (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 patien 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 palpbrae (+), 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 Problem Identification: 1. A 57 years old women, hospitalized since 6 th September 2012 with chief complaint general body weakness since 1 days before admitted. 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 patien 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. 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 icteric manifest? 2. How is the diagnosis of this patient? 3. How are the etiology of this disease? 4. How are the patogenesis of this disesase? 5. How to treat this patient? 6. How is the prognosis of this patient?

Synthesis How is the icteric manifest?

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 -Cholestasis -Dubin Johnson Syndrome -Rotor Syndrome -Non Cholestasis -Cholestasis intrahepatic -Alcohol hepatitis -Viral Hepatitis -Genetic

Cholestasis extrahepatic - Parasit infestation - Choledocholithiasis Malignant - Gallbladder cancer - Cholangiosarcoma - Pancreatic cancer

2. Hyperbilirubinemia non conjugated -Sindrom Gilbert -Sindrom Crigler-Najjar -Hemolysis

Quo ad vitam Quo ad functionam

: Dubia ad bonam : Dubia ad malam

Appendix Follow up 7th September 2012 S : General Appearance : Sense O :BP HR : : : RR: T :

Head

: Exopthalmus or endopthalmus (-), pale conjunctivae palpebrae (+), icteric sclera (+).

Neck

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

Thorax o Lungs o I o P o P o A o Cor o I

: Symetric, retraction (-).

: Static, dynamic, right and left lung symetric : Stem fremitus right = left : Sonor in both side of lungs : Vesicular (+) normal, ronchi (-), wheezing (-)

: Ictus cordis cant be seen

o P o P

:Ictus cordis cant be palpated : Upper border: ICS II Right border: parasternal dextra line Left border: axilaris anterior sinistra line Lower border: ICS V midclavicularis line

o A

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

Abdomen o I o P : Convex : Tender pain at palpation in epigastric region, hepar isnt palpable o P o A : Undulation (-), Shifting dullness (+) : Normal bowel sound

Upper and lower extremities : pretibial edema (-)

Follow up 8th September 2012 S : General Appearance : Sense O :BP HR : : : RR: T :

Head

: Exopthalmus or endopthalmus (-), pale conjunctivae palpebrae (+), icteric sclera (+).

Neck

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

Thorax o Lungs o I o P o P o A o Cor o I o P o P

: Symetric, retraction (-).

: Static, dynamic, right and left lung symetric : Stem fremitus right = left : Sonor in both side of lungs : Vesicular (+) normal, ronchi (-), wheezing (-)

: Ictus cordis cant be seen :Ictus cordis cant be palpated : Upper border: ICS II Right border: parasternal dextra line Left border: axilaris anterior sinistra line Lower border: ICS V midclavicularis line

o A

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

Abdomen o I o P : Convex : Tender pain at palpation in epigastric region, hepar isnt palpable o P o A : Undulation (-), Shifting dullness (+) : Normal bowel sound

Upper and lower extremities : pretibial edema (-)

Follow up 9th September 2012 S : General Appearance : Sense O :BP HR : : : RR: T :

Head

: Exopthalmus or endopthalmus (-), pale conjunctivae palpebrae (+), icteric sclera (+).

Neck

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

Thorax o Lungs o I o P o P o A o Cor o I o P o P

: Symetric, retraction (-).

: Static, dynamic, right and left lung symetric : Stem fremitus right = left : Sonor in both side of lungs : Vesicular (+) normal, ronchi (-), wheezing (-)

: Ictus cordis cant be seen :Ictus cordis cant be palpated : Upper border: ICS II Right border: parasternal dextra line Left border: axilaris anterior sinistra line

Lower border: ICS V midclavicularis line o A : HR 90 x/m, murmur (-), gallop (-)

Abdomen o I o P : Convex : Tender pain at palpation in epigastric region, hepar isnt palpable o P o A : Undulation (-), Shifting dullness (+) : Normal bowel sound

Upper and lower extremities : pretibial edema (-)

REFFERENCES 1. Price SA & Wilson LM. Disturbance of gastrointestinal system. In: Price SA & Wilson LM. Textbook of Pathophysiology: Clinical Concepts of Disease Process. Jakarta:EGC 2008; 484.