Case Report

( Cirrhosis hepatis )

koas interna period june-august 2009 Nik Nur Sukma 030.05.267

Identity
Name Sex age Marriage status Occupation Address Tribe Religion Admission date No Rekam Medis : Mr. H : male : 51 years : widower : labourer : Krasak, Tegalsari : sunda : moslem : 23 June 2009 : 608973

Anamnesis
Autoanamnesis Date : 26 Juny 2009 time : 13.15 WIB venue : rengasdengklok Chief complaint : distended and bloated stomach 15 days prior admittance.

History of Present Illness

15days prior to hospital admittance patient felt bloated which worsen after each meal. Patient notices increase in body weight and waist length. Patient claim normal micturation and defecation without blood or black stool.

3 days prior admittance patient felt nausea and vomiting. He also complains of fever and headache. Patient had no appetite throughout the day. Patient condition didnt get any better after he take paracetamol and decided to come to the hospital to seek medical attention.

2months ago, patient have jaundice, high fever, vomiting, headache and abdominal discomfort and was hospitalize for 3days. Patient also suffered swollen feet which got better at the time of hospital discharged.
Patient denied taking unprescribe drugs. He has no transfusion history. Patient denied taking recreational drugs, smoking or alcohol intake. Patient often have headache and confess of taking over-thecounter drugs such as paramex and jamu warung 3 times per week to ease the pain. Patient exercise 2x/weeks and eat regularly

Family History

allergy () DM () Hypertension () Asthma (-)

Physical Examination
General Appearance consciousness : compos mentis Position : berbaring telentang height : 169 cm weight : 51 Kg BMI : weight(Kg) / height2 (M) = 17.86 Patient cooperation : Cooperative Mobilization : Active

Vital signs: TD = 120/80 mmHg N = 104 x/minute, volume medium, regular rhythm, equal right-left P = 35 x/minute, regular rhythm, abdominothorakal, dispnoe(-), Stridor (-), Wheezing (-), Ronchi (+) S = 36,2 0C, left aksila

Integument decrease turgor, atrofi (-), normal body hair distribution,falling hair(-). Dark skin, ptechie (-), ikterik(-), pale skin (-), cyanosis(-), rose spot(-) Normal skin moisture

Lymph nodes Submandibula : no enlargement Subklavikula : no enlargement Supraklavikular: no enlargement Head shape : normocephali Facial expression: calm hair : black, normal distribution, grey hair(+)

Eyes

Alis : black, normal distribution Exopthalmus : -/Enopthamuls : -/Reflek cahaya langsung : +/+ Reflek cahaya tidak langsung : +/+ CA +/+, SI +/+ Lens : cloudy Pupil : sferis, isokor Oedem : -/-

Ears shape : normolalia Tuli : -/ Serumen : +/+ Secretion : -/ Membrane tympani : intact

Mouth lips : cyanosis(-) Gums and mucosa : pink, ulcer(-),hiperemis(-) tongue : coated tongue(-) Halitosis(-)

Neck simetris Tiroid : no enlargement Lymph nodes : no enlargement JVP normal

Pulmonary I : simetris lung expansion P : vokal fremitus equal in both lung P : sonor, lung-liver ,lung-gaster ,heart in normal range A : vesicular breathing sound, Rh-/-, Wh-/-

Kardiovaskuler I : iktus cordis not detected. A : BJ I-II reguler, murmur (-), gallop(-) Abdomen I : distended (+), vein dilation (-), smilling umbilicus (+), spider nevi (-) A : bowel sound 2x/menit P : shifting dullness (+) P : Nyeri tekan (-), nyeri lepas(-), defence muscular (-), hepatomegaly, lien, vesica felea, and kidney not palpate able

Ekstremitas warm, oedem -/-, palmar eritem -/-, ptechie -/-

Lab finding (25 June 2009)

Hb : 8,5 g/dl decrease Ht : 24 vol % decrease Trombosit :93000u/L decrease Leukosit : 5300u/L Bil. Total : 3,33 mg% Bil. direct : 1,25 mg% increase Bil. Indirect : 2,08 mg% increase

Protein total : 8,06mg% Protein albumin : 1,63 mg% decrease Protein globulin : 5,47 mg% increase SGOT : 70 U/L increase SGPT : 57 u/L increase HBsAg : positive Ureum : 28,1 mg/dl Creatinin : 0,98 mg/dl Current blood sugar level: 147 mg% Imaging USG is recommended

Working Diagnosis

Cirrhosis Hepatis

Differential Diagnosis

Hepatitis onset of jaundice over days or weeks

CHF Hepatomegaly,ankle oedeme

Therapy
Lasix Digoxin Aldazid Ceftriakson 2x1 amp 2x1 tablet plasbumin 25% 100cc 1x1gr

Preventing complications

Ascites Salt restriction is often necessary, as cirrhosis leads to accumulation of salt (sodium retention). Diuretics may be necessary to suppress ascites. Esophageal variceal bleeding For portal hypertension, propranolol is a commonly used agent to lower blood pressure over the portal system. In severe complications from portal hypertension, transjugular intrahepatic portosystemic shunting is occasionally indicated to relieve pressure on the portal vein. Hepatic encephalopathy

Hepatorenal syndrome The hepatorenal syndrome is defined as a urine sodium less than 10 mmol/L and a serum creatinine > 1.5 mg/dl (or 24 hour creatinine clearance less than 40 ml/min) after a trial of volume expansion without diuretics. Spontaneous bacterial peritonitis Cirrhotic patients with ascites are at risk of spontaneous bacterial peritonitis.
Decompensated cirrhosis In patients with previously stable cirrhosis, decompensation may occur due to various causes, such as constipation, infection (of any source), increased alcohol intake, medication, bleeding from esophageal varices or dehydration. It may take the form of any of the complications of cirrhosis listed above. Patients with decompensated cirrhosis generally require admission to hospital, with close monitoring of the fluid balance, mental status, and emphasis on adequate nutrition and medical treatment.

Management

Conservative management of cirrhosis must include nutritional

counseling, management of ascites, management of esophageal

varices, management of coagulopathies, monitoring for HCC, and monitoring of basic liver functions.

The ultimate treatment is liver transplant. This is an area whose success rate has soared in the last decade. It is also an area of significant controversy relative to indications, cost, and role in patients with significant comorbid conditions.

Prognosis

Ad vitam : dubia ad bonam Ad fungsionam : dubia ad bonam Ad sanationam : dubia ad malam

Thank You