Case Report

A 51 Years Old Female Came to The Hospital

with Chief Complaint The Enlargement of
Abdominal Bulging became Worse since One
Day before Admission.
By :
Much. Apriyanto, S.Ked (04061001008)
Khori Pretika, S.Ked (04061001111)

Advisor :
Prof. Dr. H. Eddy Mart Salim, SpPD, K-AI

IDENTIFICATION

Name
Age
Sex
Address
Status
Occupation
Religion
Hospitalized
Med Rec No
Weight
Height

: Mrs. E
: 51 years old
: Female
: Kenten Laut
: Married
: Mother Household
: Muslim
: August, 6th 2010 (15.00 p.m)
: 417584
: 55 kg
: 148 cm

ANAMNESIS
Chief complaint :
The enlargement of abdominal bulging became worse since
one day before admission.

History of illness :
Since 1 months before admission, Mrs.E felt her abdomen
became large, fullness and pain. She also complained about
fatigue and cant do her daily activities, decrease of
appetite, fever, nausea, but theres no blood vomit. She
also complained of yellowish eyes and tea color urine in
less volume (about two tablespoons). Her defecation was
less than usual and there is not bleeding.

About 2 weeks before admission, she felt the bulging of her

abdomen became larger and still pain. She lost her appetite
but she didnt feel her weight loss. Theres a present of
dyspnea, fever, nausea, but theres no vomit. Volume of urine
was still less (about two tablespoons) and no defecation. She
came to Muhammadyah Hospital and got the medicine
(furosemid & spironolactone).

About one day before admission in RSMH, she complained that

the enlargement of abdominal bulging became worse, pain
spread over the whole abdomen, dyspnea, fever, nausea but
theres no vomit. Volume of urine was still less and no
defecation.

 History of previous illness :

She suffered jaundice 5 years ago and was hospitalized in
RSMH.
No history of blood transfusion.
No history of hypertension.
No history of diabetes.
Familiy history :
Her mother ever got hematemesis and yellowish eyes. Then
she was hospitalized in RSMH for one months

History of Habitual
No history of consuming herbs.
No history of consuming alcohol.
She never smoke

PHISYCAL EXAMINATION (August, 8th 2010)

General Condition
Sickness condition
Consciousness
Blood Pressure
Pulse rate
Respiration rate
Temperature

: moderately sick
: compos mentis
: 100/60 mmHg
: 82
times/minute
: 26
times/minute
: 36,20 C

Specific Condition
Skin
The color of the skin is black-brown, cyanosis (-), pale on palm of
hands (+), pale on sole of feet (+), normal hair growth.
Lymph nodes
There are no enlargment of the lymph nodes on submandibular,
neck, axilaries, and inguinal.
Head
Oval, symmetrical, alopecia (-), puffy face (-), deformity (-), malar
rash (-).
Eyes
Exopthalmus (-), endopthalmus (-), edematous of superior
palpebrae (-), pale of conjungtiva palpebrae (+/+), icteric sclera
(+/+), pupils were isokor, Good light response on both of eyes,
symmetrical eyes movements.

 Nose
Normal outside appearance, no epitaksis, no obstruction.
Ear
decreasing hearing ability (-).
Mouth
Enlagrement of tonsils (-), no papils atrophy, stomatitis (-), rhagaden (-),
specific breaths smell (-).
Neck
Jugular venous pressure (5-2) cmH2O, lymph nodes enlargment (-), thyroid
gland enlargement (-), hypertrophy sternocleidomastoideus (-), stiffness (-).
Thorax
: Normal shape, spider naevi (+), pressure pain (-),
crepitation (-)
Cor
Inspection : Ictus cordis was not seen.
Palpation
: Ictus cordis was not palpable.
Percussion : Upper heart margin at 2nd intercostal space, right margin
at linea parasternalis, left margin at LMC sinistra.
Auscultation : HR 82x/menit, murmur (-), gallop (-)

 Pulmo Anterior
Inspection : Static: both hemithoraxs were symmetric.

dynamic: same movement, no retraction.

Palpation
: Stem fremitus in both hemithoraxs were equal.
Percussion : Sonorous in both of lungs, border of pulmoliver at ICS V.
Auscultation : Vesicular (+) normal in both of lungs, ronchi (-),
wheezing (-).
Pulmo Posterior :
Inspection : Static: both hemithoraxs were symmetric.

dynamic: same movement, no retraction.

Palpation
: Stemfremitus in both hemithoraxs were equal
Percussion : Sonorous in both of lungs,.
Auscultation : Vesicular (+) normal in both of lungs, ronchi (-),
wheezing (-).

 Abdomen
Inspection

:Dome shaped, umbilicus flattened, collateral

vein (+)
Palpation
: Tender, pressure pain(-), liver and spleen
difficult to be examined.
Percussion
: Percussion pain (-), shifting dullness (+).
Auscultation : Normal bowel sound
Genital
: Had not been examined
Extremities :
Upper extremity
Paint on joint (-), pale on finger (+), erythema of palm (-),
pitting edema (-/-).
Lower extremity
Pain on joint (-), varices (-), pale on sole of foot (+), pretibial
edema (+/+)

SUPPORTIVE EXAMINATION
Laboratory Finding
Result

Haemoglobin

5,2 g/dl

(12-16 g/dl)

Eritrosit

2.140.000

4,0-5,0 juta/mm3

Haematocrite

18 %

(37-43 vol%)

Leucocyte

6.400/mm3

(5000-10.000/mm3)

MCH

24

(27-31 picogram)

MCV

82

(82-92 microgram)

MCHC

29

(32-36 %)

Trombosit

158.000

200000-500000 mm

ESR

100

< 15 mm/jam

DC

0/1/3/62/32/2

0-1/1-3/2-6/50-70/20-40/2-8

Blood chemical examination

BSS
Cholesterol
HDL
LDL
Trigliseride
Uric acid
Ureum
Creatinin
Total protein
Total bilirubin
Bilirubin indirect
Bilirubin direct

Result
191
70
18
40
62
5,6
59
1,6
6,9
4,85
4,07
0,78

<200 mg/dl
< 200 mg/dl
> 65 mg/dl
< 130 mg/dl
< 150 mg/dl
2,6 6,0 mg/dl
15-39 mg/dl
0,6-1,0 mg/dl
6,0 7,8 g/dl
0,1 1,0
< 0,25
< 0,75

Na
K
TIBC
SGOT
SGPT
Alkalifosfatase
Albumin
Globulin
Fe

119
2,9
243
85
25
94
2,4
4,5
71

135- 155
3,5 5,5
253 - 435
<40
< 41
<105
3,5-5,0 g/dl
32 145 ug/dl

Urinalisa
Result
Epitel

Leukosit

3-4

0 -5 /lpb

Eritrosit

2-3

0 1/lpb

Protein

Glukosa

Bilirubin

Urobilinogen

8,0

3,2

Nitrit

Feses examination
Result
Macroscopic

Brown colour

Consistention

Soft

Amuba

Eritrosit

0-2

< 1/lpb

Leukoasit

0-1

< 1 lpb

Bacteria

FOB

USG Abdomen
Liver : small size, uneven surface, parenchymal rude, blunt
edge, ascites (+), No spleenomegali.

WORKING DIAGNOSIS
Cirrhosis Hepatic Decompensata + hiponatremi+
hipokalemia + Anemia cronic disease

DIFFERENTIAL DIAGNOSIS
Congestive Heart Failure
Hepatoma
Malnutrisi

TREATMENT
Non-pharmacology:
Bed rest
Liver diet III (2000 calories, proteins 1 g/kgs body weight,
low sodium diet)
Blood transfusion

Pharmacology:

IVFD D5% gtt x/m (micro)

Spironolacton 3 x 100 mg
Propanolol tab 3 x 10 mg
Curcuma 3 x 1 tab
Omeprazol 1 x 20 mg
Vit B1 B6 B12 3x1 tab

PLANNING EXAMINATION
Lab :
HBSAg
Anti HCV
Endoscopy
Liver biopsy

PROGNOSIS
Quo ad vitam
: dubia
Quo and functionam : malam

FOLLOW UP
August, 9th 2010
S
Abdominal pain

General condition

Conciousness : compos mentis

Blood preassure : 110/60 mmHg

Pulse rate
: 64x/minute

Respiration rate : 20x/minute

Temperature : 36,6C
Spesific condition
Pale of conjunctiva palpebra (+/+), icteric sclera (+/+), Jugular venous pressure (5-2) cmH2O
Thorax : spider Naevi (+)
Cor: HR 78 x/menit, murmur (-), gallop (-)
Pulmo: vesiculair (+) normal, rales (-), wheezing (-)
Abdomen
Inspection : dome-shaped, collateral vein (+)
Palpation
: tender, borderline of pulmo-liver at ICS V, pressure pain (-), liver and spleen couldnt be examined.
Percussion : shifting dulness (+)
Auscultation : normal bowel sound
Extremities : pretibial edema +/+

hepatic cirrhosis + hipoalbuminemia + anemia cronic disease + insufisiensi renal

Bed rest
Liver diet II
IVFD D5% gtt X/m (micro)
Spironolacton 3x100 mg
Blood tranfusion PRC 450 cc
Albumin 20%
Curcuma 2x1

August, 10th 2010

S
(-)

General condition

Conciousness : compos mentis

Blood preassure : 110/60 mmHg

Pulse rate
: 72x/minute

Respiration rate : 16x/minute

Temperature
: 36,8C
Spesific condition
Pale of conjunctiva palpebra (+/+), icteric sclera (+/+), Jugular venous pressure (5-2) cmH2O
Thorax : Spider Naevi (+)
Cor: HR 78 x/menit, murmur (-), gallop (-)
Pulmo: vesiculair (+) normal, rales (-), wheezing (-)
Abdomen
Inspection
: dome-shaped, collateral vein (+)
Palpation
: tender, borderline of pulmo-liver at ICS V, pressure pain (-), liver and spleen couldnt be examined.
Percussion : shifting dullness (+)
Auscultation : normal bowel sound
Extremities : pretibial edema +/+

hepatic cirrhosis + Hipoalbuminemia + Hiponatremia + Hipokalemia + Anemia Cronic Disease + Insufisiensi Renal

Bed rest
Liver diet II
IVFD D5% gtt X/m (micro)
Spironolacton 3x100 mg
Curcuma 3x1tab
Albumin 20%
Blood Tranfusion PRC 450 cc
KCl 3 x 1

By

Khori