Sirhep Final
Transcript of Sirhep Final
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Case Report
A 71 Years Old Male With Chief Complaint EnlargedAbdomen Back Since a Week Before Admission
By:
Darma Jupriadi Tampubolon, S.Ked
Julyanty Manurung, S.Ked
Prof. Dr. Eddy Mart Salim, Sp.PD-KAI
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Identification
Name : Mr. U
Sex : Male
Age : 71 Years Old
Address : Sungai Lilin
Status : Married
Occupation : Farmer
Religion : Moslem
Date of admission : February 16th 2012
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Chief Complaint
Enlarged abdomen back since about a week
before admission
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4 month before admitted
The patient complained enlarged abdomen, its evenlydistributed and not felt a bulge, the patient feels tightpants, without starting the swelling on both legs andpuffy eyes in the morning, feel weak, epigastric pain
and pain didnt spread to another place, nausea, bloodvomit, 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 feelmore 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 complaintsbecome decrease and patient go home.
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1 month patients complained of abdominal re-
enlarged and taking medication from a doctor inorder 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 aquaglass , no blood faeces, fluid faeces, and swollen
legs. Then he came to RSMH and hospitalized.
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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
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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
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Specific Examination
Skin
Skin color is black brown, normal pigmentation,eflorescense, icteric, sianotic or pale on palm and
plantar (-), scar (-), hyperhidrosis (-), normal hairgrowth, good turgor, wet or dry in palpation (-).
Lymph nodes
There are no enlargement of the lymph nodes onsubmandibular, neck, axillaries, and inguinal.
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Head
Normocephaly, hair loss(-), symmetrical, alopecia (-),
brittle hair (-), corn hair (-), puffy face (-), deformity (-),mallar rash (-), tenderness (-).
Eyes
Exopthalmus or endopthalmus (-), pale conjungtivaepalpebrae (+), icteric sclera (+), swelling of palpebra(+), good light response on both of eyes, symmetricaleyes movement, blurry vision (-).
Nose
Epistaxis (-), deviated septum (-), normal mucus layer.
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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 (+).
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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 (-)
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Heart
I : ictus cordis cant be seen
P : ictus cordis cant be palpated
P : Top border of cor is left ICS IIRight 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 (-)
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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
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Upper extremity
Pain on joint (-), pale on finger (-), erythema ofpalm (+), pitting edema (-), clubbing finger (-),
tremor (-), chorea (-), subcutaneus nodul (-),
marginatum eriteme (-), normal physiologicalreflex, cyanosis (-)
Lower extremity Varices (-), pretibial edema (+), pain on joint (-),
pale on finger (-), normal physiological reflex.
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Laboratory (February 16th 2012)
Hemoglobin : 6,5 gr%
Eritrocyte : 2.550.000 /mm3
Hematocryte : 21 vol%
Leucocyte : 13.400
LED :68
Trombocyte : 247.000
DC : 0/2/2/72/13/7
MCH : 21 picogram
MVC : 80 g
MCHC : 31 %
Bil. total : 2,9 mg/dl-
Bil. direk : 1,0 mg/dl-
Bil. indirek : 1,9 mg/d
Uric acid : 8,9 mg/dl
Ureumia : 59 mg/dl
Creatinin : 1,4 mg/dl
Protein total : 5,1 g/dl
Albumin : 1,9 g/dl
Globulin : 3,2 g/dl
Natrium : 143mmol/l
Kalium : 4,7 mmol/l
LDH : 697 U/L
BSS : 128 mg/dl
HbSAg : (-)
Anti HCV : (-)
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Urinalysis (February 27th 2012)
Sediment:
Epitel cell : -
Leukocyte : -
Erytrocyte : - Cylinder : -
Crystal : -
Protein : -
Glucose : negative
pH : 5,0
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Abdominal USG
Liver cirrosis with portal hipertension
(splenomegaly)
Planning examination
Repeat blood
Endoscopy Benzidine test
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Working Diagnosis
Hematemesis ec Liver Cirossis Decompensate
+ Anemic
Differential Diagnosis
Nehprotic Syndrome
Malnutrition
Dekompensate of right cardiac
Hepatocellurer carsinoma
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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
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Prognostic
Quo ad vitam : Dubia ad malam
Quo ad functionam : Dubia ad malam
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THANK YOU
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QUESTIONS