Laporan Kasus

Case Report

A 57 Years Old Man Came With Abdominal Enlargement Since 4 Months Before Admission

By:

Ariana Deviana, S.KedSeftiani, S.Ked

Advisor:

Prof. dr. Eddy Mart Salim, SpPD, K-AI

Obligate Opponents

Free Opponents

Septyan Putra Y, S.KedCeyka Maduma, S.KedKhairunnisa, S.KedFilissa T H,S.KedMuthmainnah A, S.KedMardalena, S.KedRizky A A, S.KedStella, S.KedYossi Febrizky, S.KedRamadhani, S.KedStefani G, S.KedAlfatul, S.KedAnugerah Justi P, S.KedNadia Ayu, S.KedRetno S, S.KedTri A, S.Ked

Sundari Hervinda, S.Ked Noviyanti E, S.KedLastri R S, S.KedInta A, S.KedRizky Amy L, S.KedGusnella I, S.Ked

Byanka F,S.KedLuqman,S.KedSriwulan R.P, S.Ked Aditya C, S.Ked

Dwika P, S.KedLeonardus, S.Ked

Imanda Husna S, S.Ked Ayu Hasim, S.KedRidho F, S.KedRizki D,S.KedAtika Wulandari, S.Ked

Novrilia K, S.KedCindy, S.KedDEPARTMENT OF INTERNAL MEDICINE

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY

DR. MOHAMMAD HOESIN GENERAL HOSPITAL2014APPROVAL PAGECase ReportTitleA 57 Years Old Man Came With Abdominal Enlargement Since 4 Months Before AdmissionBy:

Ariana Deviana, S.KedSeftiani, S.KedHas been accepted and approved as one of the qualification in senior clerkship at Internal Medicine Department Dr. Mohammad Hoesin Hospital Palembang on November 17th 2014 January 26th 2014.

Palembang, December 2014 Prof. dr. Eddy Mart Salim, SpPD, K-AI

PREFACE

We give thanks to Prof. dr. Eddy Mart Salim, SpPD-KAI as our advisor. We are grateful that this case report can be finished according to the schedule. We give thanks to the contribution of every person in finishing this case report. This case report is about cirrhosis hepatic. We hope that this case report will be useful for our colleagues in internal medicine department so that we apply the adequate diagnosis and treatment for the patients.

Palembang, December 2014 AuthorCONTENT PageCOVER PAGE i

APPROVAL PAGE ii

PREFACE iii

CONTENTS ivCHAPTER I INTRODUCTION 1CHAPTER II CASE REPORT 3CHAPTER III CASE ANALYSIS 13REFERENCES 19CHAPTER I

INTRODUCTION

Cirrhosis hepatic is a complication of many liver diseases characterized by abnormal structure and function of the liver. This disease is defined histologically as a diffuse hepatic pathologic process characterized by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules.This fibrosis process, which is defined as an excess deposition of the components of the extracellular matrix (such as collagens, glycoproteins and proteoglycans) within the liver. This response to liver injury potentially is not a reversible process. Cirrhosis represents the final common histologic pathway for a wide variety of chronic liver disease. The term cirrhosis was first introduced by Laennec in 1826. It is derived from the Greek term scirrhus or kirrhos refers to the orange or tawny surface of the liver seen at autopsy.1World Health Organization (WHO) estimates prevalence of cirrhosis hepatic in 2006 is up to 170 million cases. This report reflects that approximately 3% of human world population have cirrhosis hepatic.2Cirrhosis hepatic affects an estimated 7 million individuals in Indonesia. The prevalence of this disease in Indonesia is approximately 1-2,4% in 2007. Cirrhosis predominantly occurs in man than woman, with a male-to-female ratio is 2-4:1.The prevalence of this disease is highest in aged 40-50 years.3 This disease is the seventh leading cause of death in the world and is responsible of 25.000 of all deaths per year. There are 20-40% cases of cirrhosis, due to any causes, increases the risk of primary liver cancer (hepatocellular carcinoma). Primary refers to the fact that thetumor originates in the liver.4In cirrhosis, the relationship between blood and liver cells is destroyed. Even though the liver cells that survive or are newly-formed may be able to produce and remove substances from the blood, they do not have the normal, intimate relationship with the blood, and this interferes with the liver cells ability to add or remove substances from the blood. In addition, the scarring within the cirrhotic liver obstructs the flow of blood through the liver and to the liver cells. As a result of the obstruction to the flow of blood through the liver, blood "backs-up" in the portal vein, and the pressure in the portal vein increases, a condition calledportal hypertension.5Because of the obstruction to flow and high pressures in the portal vein, blood in the portal vein seeks other veins in which to return to the heart, veins with lower pressures that bypass the liver. Unfortunately, the liver is unable to add or remove substances from blood that bypasses it. It is a combination of reduced numbers of liver cells, loss of the normal contact between blood passing through the liver and the liver cells, and blood bypassing the liver that leads to many of the manifestations of cirrhosis. This condition refers that the cirrhosis hepatic has fallen into the decompensated phase. And it can lead to increase the morbidity and mortality rate in patient with cirrhosis hepatic.6With this kind of data, we can conclude that cirrhosis hepatic is a disease that needs a special attention, because, this disease is a chronic progressive that may increase morbidity and mortality if we dont act in a professional manner. Appropriate theraphy can be done if the medical practitioner is familiar with the risk factors, etiology, pathogenesis, clinical signs and symptoms of cirrhosis hepatic. Therefore, we take this case as a case presentation with our expectations is as a medical practitioner, we can identify this disease and able to make a clinical diagnosis so this case can be managed appropriately. We hope it will help to reduce the incidence of morbidity and mortality caused by cirrhosis hepatic.CHAPTER IICASE REPORT

I. ANAMNESIS(November 24th 2014, 05.00 pm)

1. Identification

a. Name

: Mr. I bin S

b. Age

: 57 years old

c. Sex

: Male

d. Religion

: Moeslim

e. Status

: Married

f. Occupation : Rubber Farmer

g. Address

: Village II, Sukamaju District, Muara Enim

h. Medical Record: 858892

i. Date of Admission: November 20th 2014, 11.35 am.2. Chief Complaint

Abdominal enlargement since 4 months before admission.

3.Historyof Illness

+4 months before admission, patient complained about abdominal enlargement, full on abdominal, weak (+), loss of appatite (+), difficult to defecation (+). Nausea (-), vomiting (-), epigastric pain (-), upper right abdominal pain (-), fever (-), cough (-), shortness of breath (-), night sweating (-), yellowish body (-), yellowish eye (-), swelling of entired body (-), swelling of eye (-), no abnormality in urination. Patient went to a shamanand he got lime water. But, the patient feels that there is no improvement.+2 months before admission, patientcomplained his abdomen is more enlarge, enlargement is on all of the area of abdomen, full on abdominal. Patient also complained about enlargement of the breasts, swelling on both of his legs, weak (+), loss of appatite (+). Black defecation (-), nausea (-), vomiting (-), yellowish body (-), yellowish eye (-), swelling of entired body (-), swelling of eye (-). Patient went to a shamanagain but there are no improvement.

+10 days before admission, patient still complained about abdominal enlargement, swelling on both legs (+), enlargement of breasts, constipation (+), nausea (-), vomiting (-), weak (+), loss of appatite (+), black defecation (-), nausea (-), vomiting (-), yellowish body (-), yellowish eye (-), swelling of entired body (-), swelling of eye (-), no abnormality on urination.Then patient went to RSMH Palembang.

4. History of Past Illness

History of hypertension is denied

History of diabetes mellitus is denied

History of jaundice is denied

History of alcoholic drinking is denied

History of blood transfusion is denied

History of traditional medicine consumption is denied

History of drug consumption (+) ( patient consumped Acetosal, 1 tablet/day, since + 10 years ago.

History of smoking (+), since he was 15 years old, 1-2 packs/day.

5. Historyof Familial Disease

History of similar complaints with patient in the family is denied

II. PHYSICAL EXAMINTAION(November 24th 2014, 05.00 pm)

a. General Condition

General appearance: looked moderately sick

Conciousness: compos mentis

Blood pressure: 110/70 mmHg

Pulserate

: 72x/minute, regular

Respiration rate: 20x/minute, regular, dyspnea (-), orthopnea (-)

Temperature: 36,3 C

Body weight: 46 kg

Body height: 160 cm

RBW

: 77% (Underweight)

Abdominal circumference: 90 cm

b. Specific Condition

SkinSkin color is brown, abnormal pigmentation (-), efflourecention and scar (-), icteric (-).

Lymph Glands

There are no enlargement of the lymph node on submandibular, neck, axilary, and inguinal.

Head

Normocephaly, alopecia (-), symmetrical face shape (+), deformity (-)

Nose

Epistaxis (-), normal nasal septum, normal mucous layer, secret (-).

Eye

Exopthalmus (-/-),edematous palpebra (-/-), pale of conjunctiva palpebrae (+/+), icteric sclera (-/-). Pupil round isokor (+), light reflex (+/+), diameter 3mm, symmetrical eyes movement. Ear

No abnormality on meatus auditory externus, secret (-)

Mouth

Lips : cyanotic (-), fissure (-), no gum hypertrophy (-), tongue atrophy of the optic disc (-) Neck

Jugular Vein Pressure/JVP (5-2) cmH2O, no enlargement of lymph nodes, no enlargement of thyroid gland, no deviation of trachea.

Axilla

Alopecia axillaries (+)

Thoracic

Normal shape,gynecomastia (+), spider naevi (+)

Cor

I : Ictus cordis is not seen

P : Ictus cordis is not palpable

P : Upper boundary of cor is ICS II Right boundary of cor is linea sternalis dextra

Left boundary of cor is linea midclavicula sinistra ICS V. A : HR=72x/minute, regular, murmur (-), gallop (-)

Pulmo

I: Static : symmetrical of right and left side are equal

Dynamic : same movementof right and left lung

Retraction of intercostal space (-)

P: Stemfremitus right = left

Pain on palpation (-)

P: Sonor on all area of right and left lung

Border of lung and liver on ICS V

Shifting of border on inspiration is two intercostal space

A: Vesicular (+) normal, ronkhi (-), wheezing (-) Abdomen

I: distended, venectation (+), caput medusa (-)

P: soft, tenderness (-), liver and lien are difficult to palpation

P: shifting dullness (+), undulation (+)

A: normal bowel sounds

Extremities :

Upper: pale (-), palmar erythema (-), white nail (+)Lower: edematous of pretibial (+/+), white nail (+) External Genitalia : testicular atrophy (-)

III. ADDITIONAL EXAMINATIONa. LaboratoryExamination (November 21st, 2014)NoLaboratoryResultNormal ValueInterpretation

1Hemoglobine9,113-17 g/dLAnemia

2Erythrocite2,834,20-4,87 103/mm3

3Hematocrite2843-49 vol%

4Leukocyte64005000-10000/mm3

5Platelet78150-400 103/LThrombocytopenia

6Diff count

Basophil

Eosinophil

Segment

Band

Lymphocyte

Monocyte0

7

0

66

20

70-1 %

1-6 %

2-6 %

50-70 %

25-40 %

2-8%

7BSS118