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Chronic Hepatitis B
Case Report : dr. Irwin Sp.PD
Rengasdengklok
June 4th 2012
Sundanese
Moeslem
Room
Admission
Ethnic
Religion
Last Education
D3
Marital Status
Married
Truck Driver
Saptamarga 06/03, Sinarbaya. Teluk
Jambe
52 y.o
Mr. T
Job
Address
Age
Name
IDENTITY
Main
Complai
nt
Enlarged of the
stomach since 3 month
before hospitalized
Addition
al
Complai
nt
Dyspnoe
Nausea
Oedem in both
extremities
Anamnese
DM (+)
Asthma (-)
Heart
Disease (-)
Histor
y of
Past
Diseas
e
Hypertensi
on (-)
Hepatitis B
(+)
DM (+)
Hypertensi
on (-)
Asthma (-)
Same
illness (-)
Liver
Malignanc
y (-)
Drugs consumption
Body Excercise
Tatoos
Alcohol
Smoking
Carbonated Drinks
Traditional Drinks
Habits History
General Condition
General appearance
Moderately ill
Consciousness
Compos mentis
VITAL SIGNS
Blood
Pressur
e
90/60
mmH
g
Heart
Rate
98x/
mins
Respir
ation
Rate
28x/
mins
Temper
ature
36,0
C
Normocephali
Eyes
Mout
h
Neck
Head
Physical Examination
Thorax Examination
- Lung examination
Inspection
Palpation
Percussion : Sonor
Auscultation
: Vesicular breath sound
in both lung, no ronchi and wheezing
ABDOMINAL EXAMINATION
Inspection
: Brown skin,distended , skin abnormality (-),
Vein dilatation (-)
Palpation
:
Sociable
Abdominal tenderness at upper right abdomen (+)
Liver not palpable
Enlargement of spleen in Schuffners Point 2.
Percussion
:
No pain present on abdominal percussion
Sounds dull
Shiffting dullness (+)
Undulation (+)
Auscultation :Bowel sound (+), arterial bruit (-), venous
hum(-)
Extremity
Examination
Warm acrals
Oedema
(Pitting oedema (+))
LABORATORY FINDING
May, 22th 2012
Result
Normal
Hb
7,0
12 17 g%
Leukocyte
2800
5 10 rb
Trombocyte
178.000
150 450rb
Ht
21
37 48 %
GDS
243
80 140 mg/dl
Ureum
19.5
10 45 mg/dl
Creatinine
1.05
Result
Normal
HBsAg
SGOT
28
< 40 u/L
SGPT
17
< 40 u/L
Protein total
6,83
Albumin
1,98
Globulin
4,85
RESUME
Blood Test
Adjuvant Test
Anemic
Conjungtiva +/+
Tenderness at
upper right
abdomen
Enlargement of
spleen in
Schuffners Point
2.
Shiffting
dullness (+)
Undulation (+)
Palmar Erytema
Physical
Examination
Anamnese
Enlargement of
the stomach
dyspnoe,nausea
pain at upper
right abdomen,
oedem
extremities
Hepatitis B, DM
Drinking alcohol,
traditional
drinks, and
sodas.
Hb 7,0
Leukocyte 2800
Ht 21
Albumin 1,98
Globulin 4,85
Differential Diagnosis
Chirrosis
Hepatis e.c
Alcohol and DM
type 2
Chirrosis
Hepatis e.c
Chronic
Hepatitis B and
DM type 2
Working Diagnosis
Chirrosis Hepatis e.c Chronic
Hepatitis B
DM type 2
Suggested Examination
USG Abdomen
GGT
EKG
Thorax Photo
Treatment
Medicamentosa
IVFD D5 8dpm
Lasix 20 amp
Spironolacton 3x1
Aminofusin Hepar 1x1
Humalog 3x16 U
Inj. Ceftriaxon 2gr
Albumin 20 % 100cc
Non-Medicamentosa
Nutritional Therapy
Paracyntesis
Prognosis
Ad Vitam
: Dubia ad Bonam
Ad Fungtionam : Dubia ad
Malam
Ad Sanationam : Dubia ad
Malam