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