CHAPTER II CASE REPORT II.1 IDENTIFICATION Name : Mrs.

. N Age : 60 years old Sex : female Address : Cempaka Dalam Status : married Occupation : housewive Hospitalized : October, 9th 2009 (12.40 a.m) II.2 ANAMNESIS Chief of complaint Bulging of the abdomen that became even larger since two weeks before admission History Of Illness 2 months before admission, the patient complained about bulging of her abdomen, her bulging abdomen seemed to spread evenly so she found some difficulty in wearing her outfits. The patient felt uncomfort, heavy, and full of stomach that caused the decrease in her appetite, there was no constant pain on her abdomen. There was no nausea, vomiting, or fever. Her body became weak. In addition, both of her legs were swollen too, but she neither had the swelling eyelids especially when she woke up in the morning nor itching on her skin. Because of her bulging abdomen, she sometimes felt shortness of her breath (dyspnea). Her dyspnea were not caused by her activities, emotional conditions, weathers, and never produced ngik sound. She still can sleep with one pillow, she never woke up in the middle of her night-time sleep because of short winded. She said sometimes she may had dark yellow or brown colored urine, but never passed black or bloody stools. Theres no others complaint in defecation and urination habits. She went to the local health care center and took some medicines (she didnt know name of drugs) but there was no improvement. 2 weeks before admission because of her abdomen seemed even more larger and tense, she had nausea and vomits, three times, containing all foods and fluids that she had been consumed that day. There was no blood in her vomit and no dark/bloody stools. Then, she was hospitalized in Moh. Hoesin Hospital in order to receive some better treatments. History of past illness No history of liver disease No history of blood tranfusion No history of consuming alcohol History of consuming herbal medicines homemade admitted History of hypertension History of familys diseases There is no patients family who have the same complaints of the disease

II.3 PHISYCAL EXAMINATION General condition (10, 9th 2009) General condition: sick Sickness condition : moderate sickness Conciousness : compos mentis Blood preassure : 180/100 mmHg Pulse rate : 108x/minute, regular, equal. Respiration rate : 20x/minute, regular (thoracal type) Temperature : 36,50C Nutrition state : normoweight (BW: 60 kgs; H: 150 cms, BMI: 19,53) Dehydration : (-) Spesific condition Skin The color of the skin is black-brown, eflorescency and scar (-), abnormal pigmentation (-), enough turgor, icteric (-), cyanosis (-), pale on palm of hands (-), pale on sole of feet (-), spider naevy (-), subcutaneous nodul (-), 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 Epistaxis (-), normal nasal septum, normal mucous layer. Ear Normal both of meatus accusticus externus, decreasing hearing ability (-). Neck Jugular venous pressure (5-2) cmH 2O, lymph nodes enlargment (-), thyroid gland enlargement (-), hypertrophy sternocleidomastoideus (-), stiffness (-). Thorax Cor : ictus cordis was not seen : ictus cordis was not palpable : Normal shape, spider naevy (-)

Inspection Palpation

Percussion

: upper heart margin at 2nd intercostal space, right margin at linea sternalis, left margin at LMC sinistra Auscultation : HR 108x/menit, murmur (-), gallop (-) Pulmo Anterior Inspection : static: both hemithoraxs were symmetric, spider naevy (-). dynamic: same movement, no retraction Palpation : stemfremitus in both hemithoraxs were equal Percussion : sonorous in both of lungs, border of pulmo-liver at ICS V Auscultation : vesiculair (+) normal in both of lungs, rales (-), wheezing (-). Pulmo Posterior Inspection : static: symmetric and dynamic: same movement, no retraction Palpation : stemfremitus in both hemithoraxs were equal Percussion : sonorous in both of lungs Auscultation : vesiculair (+) normal, rales (-), wheezing (-) Abdomen Inspection : dome shaped, umbilicus flattened, collateral vein (+) Palpation : tender, pressure pain(-), liver and spleen can not be examined. Percussion : stony dull, fluid wave test (+) Auscultation : normal bowel sound Genital : Vulva edema (-) 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 (+/+).

BSS Total cholesterol HDL-cholesterol LDL-cholesterol Triglyceride Uric acid Ureum Creatinine Total protein Albumine Globulin Total bilirubin Direct bilirubin Indirect bilirubin SGOT SGPT Natrium Kalium Urine analysis Epitel Leukocite Erythrocite Protein Glucose

: 161 mg/dl : 170 mg/dl : 55 mg/dl : 110 mg/dl : 125 mg/dl : 5,4 mg/dl : 30 mg/dl : 1,3 mg/dl : 6,7 g/dl : 2,1 g/dl : 4,6 g/dl : 0,78 mg/dl : 0,19 : 0,49 : 32 U/l : 20 U/l : 137 mmol/L : 4,8 mmol/L : positive : 2-3/ HPF : 0-1/ HPF : negative : negative

(<200 mg/dl) (>55 mg/dl) (<130 mg dl) (<150 mg/dl) (F: 2,6-6,0 mg/dl) (15-39 mg/dl) (0,9-1,3 mg/dl) (6,0-7,8 mg/dl) (3,5-5 g/dl) (0,1-1,0 mg/dl) (<0,25 mg/dl) (<0,75 mg/dl) (<40 U/l) (<41 U/l) (135-150 mmol/L) (3,5-5 mmol/L) (0-5/HPF) (0-1/HPF)

II.4. SUPPORTIVE EXAMINATION LABORATORY FINDING Haematology (October, 9th, 2009) Haemoglobin : 8,6 g/dl (12-16 g/dl) Haematocrite : 26% (40-48 vol%) Leucocyte : 5900/mm3 (5000-10.000/mm3) ESR : 70 mm/h (<15 mm/h) Thrombocytes : 175.000/mm3 (200.000-500.000/mm3) Diff Count: Basofil : 0% (0-1%) Eosinofil Band : 0% (2-6%) Segment Limphocytes : 30% (20-40%) Monocytes Clinical Chemistry

: 0% (1-3%) : 67% (50-70%) : 3% (2-8%)

II.5 RESUME A sixty years old woman admitted to hospital on October 9th, 2009 with chief complaint bulging of the abdomen that became even larger since two weeks before admission. 2 months before admission, the patient complained about bulging of her abdomen, her bulging abdomen seemed to spread evenly so she found some difficulty in wearing her outfits. The patient felt uncomfort, heavy, and full of stomach that caused the decrease in her appetite, there was no constant pain on her abdomen. There was no nausea, vomiting, or fever. Her body became weak. In addition, both of her legs were swollen too, but she neither had the swelling eyelids especially when she woke up in the morning nor itching on her skin. Because of her bulging abdomen, she sometimes felt shortness of her breath (dyspnea). Her dyspnea were not caused by her activities, emotional conditions, weathers, and never produced ngik sound. She still can sleep with one pillow, she never woke up in the middle of her night-time sleep because of short winded. She said sometimes she may had dark yellow or brown colored urine, but never passed black or bloody stools. Theres no others complaint in defecation and urination habits. She went to the local health care center and took some medicines (she didnt know name of drugs) but there was no improvement. 2 weeks before admission because of her abdomen seemed even more larger and tense, she had nausea and vomits, three times, containing all foods and fluids that she had

been consumed that day. There was no blood in her vomit and no dark/bloody stools. Then, she was hospitalized in Moh. Hoesin Hospital in order to receive some better treatments. From physical examination we found: moderate sickness condition, vital sign within normal limit, nutrition state (in normal condition): IMT= 19,53 kgs/m2 (normoweight). There were pale of conjungtiva palpebrae (+), palmar erythema (+), icteric sclera (+), spider naevy (-), collateral vein (+), ascites (+). Laboratory findings show anemia (Hb: 8,6 g/dl), trombocitopenia (175.000/mm3), hypoalbuminenia (2,1 g/dl), decreasing in total bilirubin (direct and indirect; 0,78 mg/dl), HDL level (55mg/dl), and increasing of ESR 70mm/h, SGOT 32 U/L and SGPT 20 U/L. II.6 WORKING DIAGNOSIS Decompensated cirrhosis hepatis + anemia ec chronic disease+ hypertension stage II II.7 DIFFERENTIAL DIAGNOSIS Decompensated cirrhosis hepatis + anemia ec Fe deficiency.+ hypertension stage II II.8 TREATMENT Non-pharmacology: Bed rest Liver diet IIII (2000 calories, proteins 1 g/kgs body weight, low sodium diet) Pharmacology: IVFD RL gtt X/m (micro) Furosemid 1x40mg Spironolacton 2x100mg Vit Bcomplex 3x1tab Curcuma 3x1tab Clonidine 3x0,25 Ceftriaxon 1x1 gram II. 9 PLANNING EXAMINATION Abdominal USG Diagnostic paracentesis Liver biopsy Planning giving Human albumin 20% II.10 PROGNOSIS Quo ad vitam Quo and functionam : dubia ad malam : dubia ad malam FOLLOW UP October, 10th 2009 S O Bulging of abdomen General condition Conciousness : compos mentis Blood preassure : 140/80 mmHg Pulse rate : 80x/minute Respiration rate : 20x/minute Temperature : 36,5C Spesific condition Pale of conjunctiva palpebra (+), icteric sclera (+), exopthalmus (-) Jugular venous pressure (5-2) cmH2O, lymph nodes enlargement (-), thyroid gland enlargement (-). Cor Inspection Palpation Percussion : ictus cordis was not seen : ictus cordis was not palpable : upper heart margin at 2nd intercostal space, right margin at linea sternalis dextra , left margin at linea midclavicularis sinistra Auscultation : HR 80 x/menit, murmur (-), gallop (-) Pulmo Inspection : static: both hemithoraxs were symmetric. dynamic: same movement, no retraction Palpation : stemfremitus in both hemithoraxs were equal Percussion : sonorous in both lungs, border of pulmo-liver at ICS V Auscultation : vesiculair (+) normal, rales (-), wheezing (-) Abdomen Inspection Palpation : dome-shaped, collateral vein (+) : tender, borderline of pulmo-liver at ICS V, pressure pain (-), liver and spleen couldnt be examined. Percussion : stony-dull, fluid wave test (+) Auscultation : normal bowel sound Extremities : eritema palmar +/+

pretibial edema +/+ Decompensated hepatic cirrhosis + anemia ec chronic disease + hypertension stage II DD/ Decompensated hepatic cirrhosis + anemia ec Fe deficiency + hypertension stage II Bed rest Liver diet III IVFD RL gtt X/m (micro) Furosemid 1x40mg Spironolacton 2x100mg Vit Bcomplex 3x1tab Curcuma 3x1tab Nifedipine 4x1 Clonidine 3x0,25 Ceftriaxon 1x1 gram A

Extremities : eritema palmar +/+ pretibial edema +/+ Decompensated hepatic cirrhosis + anemia ec chronic disease + hypertension stage II DD/ Decompensated hepatic cirrhosis + anemia ec Fe deficiency + hypertension stage II Bed rest Liver diet III IVFD RL gtt X/m (micro) Furosemid 1x40mg Spironolacton 2x100mg Vit Bcomplex 3x1tab Curcuma 3x1tab Clonidine 3x0,25 Ceftriaxon 1x1 gram

October, 12th 2009 S Bulging of abdomen, coughing General condition O Conciousness : compos mentis Blood preassure : 140/70 mmHg Pulse rate : 84x/minute Respiration rate : 20x/minute Temperature : 36,6C Spesific condition Pale of conjunctiva palpebra (+), icteric sclera (+), Jugular venous pressure (5-2) cmH2O Cor: HR 84 x/menit, murmur (-), gallop (-) Pulmo: vesiculair (+) normal, rales (-), wheezing (-) Abdomen Inspection Palpation : dome-shaped, collateral vein (+) : tender, borderline of pulmo-liver at ICS V, pressure pain (-), liver and spleen couldnt be examined Percussion : stony-dull, fluid wave test (+) Auscultation : normal bowel sound

October, 13th 2009 S Dyspnea, no defecation for the last 4 days General condition O Conciousness : compos mentis Blood preassure : 140/70 mmHg Pulse rate : 84x/minute Respiration rate : 18x/minute Temperature : 36,1C Spesific condition Pale of conjunctiva palpebra (+), icteric sclera (+), Jugular venous pressure (5-2) cmH2O Cor: HR 84 x/menit, murmur (-), gallop (-) Pulmo: vesiculair (+) normal, rales (-), wheezing (-) Abdomen Inspection Palpation : dome-shaped, collateral vein (+) : tender, borderline of pulmo-liver at ICS V, pressure pain (-), liver and spleen couldnt be examined. Percussion : stony-dull, fluid wave test (+) Auscultation : normal bowel sound

Extremities : eritema palmar +/+ pretibial edema +/+ Decompensated hepatic cirrhosis + anemia ec chronic disease + hypertension stage II DD/ Decompensated hepatic cirrhosis + anemia ec Fe deficiency + hypertension stage II Bed rest O2 3-5 l/minute Liver diet III IVFD RL gtt X/m (micro) Furosemid 1x40mg Spironolacton 2x100mg Vit Bcomplex 3x1tab Curcuma 3x1tab Clonidine 3x1 Ceftriaxon 1x1 gram Dulcolax sup ( night )

spleen couldnt be examined. Percussion : stony-dull, fluid wave test (+) Auscultation : normal bowel sound Extremities : eritema palmar +/+ pretibial edema +/+ Decompensated hepatic cirrhosis + anemia ec chronic disease + hypertension stage II DD/ Decompensated hepatic cirrhosis + anemia ec Fe deficiency + hypertension stage II Bed rest O2 3-5 l/minute Liver diet III IVFD RL gtt X/m (micro) Furosemid 1x40mg Spironolacton 2x100mg Vit Bcomplex 3x1tab Curcuma 3x1tab Clonidine 3x1 Ceftriaxon 1x1 gram Dulcolax sup ( night ) Laxadine 3x1c Planning : Check haematology and clinical chemistry Abdominal USG

October, 14th 2009 S O Dyspnea, BAB (-) General condition Conciousness : compos mentis Blood preassure : 180/90 mmHg Pulse rate : 82x/minute Respiration rate : 20x/minute Temperature : 36,4C Spesific condition Pale of conjunctiva palpebra (+), icteric sclera (+). Jugular venous pressure (5-2) cmH2O Cor: HR 82x/menit, murmur (-), gallop (-) Pulmo: vesiculair (+) normal, rales (-), wheezing (-) Abdomen Inspection Palpation : dome-shaped, collateral vein (+) : tender, borderline of pulmo-liver at ICS V, pressure pain (-), liver and

October, 15st 2009 S General condition O Conciousness : compos mentis Blood preassure : 170/90 mmHg Pulse rate : 82x/minute Respiration rate : 20x/minute Temperature : 36C Spesific condition Pale of conjunctiva palpebra (+), icteric sclera (+). Jugular venous pressure (5-2) cmH2O

Cor : HR 82 x/menit, murmur (-), gallop (-) Pulmo: vesiculair (+) normal, rales (-), wheezing (-) Abdomen Inspection Palpation

Globulin SGOT SGPT TIBC Fe

: : : : :

3,4 g/dl 24 U/l 13 U/l 200 g/dl 31 g/dl

(<40 U/l) (<41 U/l) (274-385 g/dl) (32-145 g/dl)

: dome-shaped, collateral vein (+) : tender, borderline of pulmo-liver at ICS V, pressure pain (-), liver/ spleen couldnt be examined. Percussion : stony-dull, fluid wave test (+) Auscultation : normal bowel sound Extremities : eritema palmar +/+ pretibial edema +/+ Laboratory finding: Haematology Haemoglobin Haematocrite Erythrocyte MCH MCV MCHC Leucocyte ESR Thrombocytes Reticulocyte Diff Count: Basofil Eosinofil Band Segment Limphocytes Monocytes Clinical Chemistry Total cholesterol HDL-cholesterol LDL-cholesterol Triglyceride Total protein Albumin

Abdominal USG: Liver: shape and size shrunken, regular border, blunt edge, coarse parenchyma Spleen: normal shape, size slightly enlarge, ascites (+) Impression: hepatic cirrhosis with portal hypertension. A Decompensated hepatic cirrhosis + anemia ec chronic disease + hypertension stage II Bed rest Liver diet III IVFD D5% gtt X/m (micro) Furosemid 1x40mg Spironolacton 2x100mg Vit Bcomplex 3x1tab Curcuma 3x1tab Clonidine 3x1 Ceftriaxon 1x1 gram

: : : : : : : : : : : : : : :

7,2 g/dl 21% 2.420.000/mm3 29 picogram 78 gram 30% 4.800/mm3 88 mm/h 125.000/mm3 : 0,4% 0% 3% 2% 53% 38% 4% (0-1%) (1-3%) (2-6%) (50-70%) (20-40%) (2-8%)

(14-18, 12-16 g/dl) (40-48 vol%) (2.500.000-4.500.000/mm3) (27-31 picogram) (82-92 gram) (32-36%) (5000-10.000/mm3) (<15 mm/h) (200.000-500.000/mm3) (0,5-1,5%)

Planning : Human albumin 20% 50cc / day diagnostic Paracentesis ascites liquid

: 151 mg/dl (<200 mg/dl) : 14 mg/dl (>55 mg/dl) : 102 mgdl (<130 mg/dl) : 175 mg/dl (<150 mg/dl) : 4,8 g/dl (6,0-7,8 g/dl) : 1,4 g/dl (3,5-5 g/dl)

October, 16th 2009 S Headache O General condition Conciousness : compos mentis Blood preassure : 150/90 mmHg Pulse rate : 80x/minute Respiration rate : 20x/minute Temperature : 36,5C Spesific condition Pale of conjunctiva palpebra (+), icteric sclera (+). Jugular venous pressure (5-2) cmH2O

Cor: HR 80 x/menit, murmur (-), gallop (-) Pulmo: vesiculair (+) normal, rales (-), wheezing (-) Abdomen Inspection Palpation : dome-shaped, collateral vein (+) : tender, borderline of pulmo-liver at ICS V, pressure pain (-), liver and spleen couldnt be examined. Percussion : stony-dull, fluid wave test (+) Auscultation : normal bowel sound Extremities : eritema palmar +/+ pretibial edema +/+ parasintesis ascites liquid 1800 cc A Decompensated hepatic cirrhosis + anemia ec chronic disease + hypertension stage II Bed rest Liver diet III IVFD RL gtt X/m (micro) Furosemid 1x40mg Spironolacton 2x100mg Vit Bcomplex 3x1tab Curcuma 3x1tab Clonidine 3x1 Ceftriaxon 1x1 gram Albumin 20% 50 cc day 1 A

Pale of conjunctiva palpebra (+), icteric sclera (+), Jugular venous pressure (5-2) Cor: HR 84 x/menit, murmur (-), gallop (-) Pulmo: vesiculair (+) normal, rales (-), wheezing (-) Abdomen Inspection Palpation : dome-shaped, collateral vein (+) : tender, borderline of pulmo-liver at ICS V, pressure pain (-), liver and spleen couldnt be examined. Percussion : stony-dull, fluid wave test (+) Auscultation : normal bowel sound Extremities : eritema palmar +/+ pretibial edema +/+ Decompensated hepatic cirrhosis + anemia ec chronic disease + hypertension stage II Bed rest Liver diet III IVFD RL gtt X/m (micro) Spironolacton 2x100mg Vit Bcomplex 3x1tab Curcuma 3x1tab Clonidine 3x1 Albumin 20% 50 cc day 2

October, 17th 2009 S General condition O Conciousness : compos mentis Blood preassure : 140/80 mmHg Pulse rate : 84x/minute Respiration rate : 20x/minute Temperature : 36,6C Spesific condition

October, 19th 2009 S Dyspnea, coughing General condition O Conciousness : compos mentis Blood preassure : 190/90 mmHg Pulse rate : 86x/minute Respiration rate : 24x/minute Temperature : 36,5C Spesific condition Pale of conjunctiva palpebra (+), icteric sclera (+), Jugular venous pressure (5-2) cmH2O

Cor: HR 86 x/menit, murmur (-), gallop (-) Pulmo: vesiculair (+) normal, rales (-), wheezing (-) Abdomen Inspection Palpation : dome-shaped, collateral vein (+) : tender, borderline of pulmo-liver at ICS V, pressure pain (-), liver and spleen couldnt be examined. Percussion : stony-dull, fluid wave test (+) Auscultation : normal bowel sound Extremities : eritema palmar +/+ pretibial edema +/+ A Decompensated hepatic cirrhosis + anemia ec chronic disease + hypertension stage II Bed rest O2 3-5 l/minute Liver diet III IVFD RL gtt X/m (micro) Spironolacton 2x100mg Vit Bcomplex 3x1tab Curcuma 3x1tab Clonodine 3x1 Nifedipine 4x1 A

Pale of conjunctiva palpebra (+), icteric sclera (+), Jugular venous pressure (5-2) cmH2O Cor: HR 80 x/menit, murmur (-), gallop (-) Pulmo: vesiculair (+) normal, rales (-), wheezing (-) Abdomen Inspection Palpation : dome-shaped, collateral vein (+) : tender, borderline of pulmo-liver at ICS V, pressure pain (-), liver and spleen couldnt be examined. Percussion : stony-dull, fluid wave test (+) Auscultation : normal bowel sound Extremities : eritema palmar +/+ pretibial edema +/+ Decompensated hepatic cirrhosis + anemia ec chronic disease + hypertension stage II Bed rest O2 3-5 l/minute Liver diet III IVFD D5% gtt X/m (micro) Furosemide 2x40 mg Spironolacton 3x100mg Vit Bcomplex 3x1tab Curcuma 3x1tab Clonidine 3x0,25

October, 20th 2009 S Epigastic pain, dyspnea, coughing General condition O Conciousness : compos mentis Blood preassure : 140/60 mmHg Pulse rate : 80x/minute Respiration rate : 20x/minute Temperature : 37,1C

Spesific condition

October, 21st 2009 S dyspnea General condition O Conciousness : compos mentis Blood preassure : 130/80 mmHg Pulse rate : 76x/minute Respiration rate : 22x/minute Temperature : 37,1C Spesific condition Pale of conjunctiva palpebra (+), icteric sclera (+), Jugular venous pressure (5-2) cmH2O

Cor: HR 84 x/menit, murmur (-), gallop (-) Pulmo: vesiculair (+) normal, rales (-), wheezing (-) Abdomen Inspection Palpation : dome-shaped, collateral vein (+) : tender, borderline of pulmo-liver at ICS V, pressure pain (-), liver and spleen couldnt be examined. Percussion : stony-dull, fluid wave test (+) Auscultation : normal bowel sound Extremities : eritema palmar +/+ pretibial edema +/+ A Decompensated hepatic cirrhosis + anemia ec chronic disease + hypertension stage II Bed rest O2 3-5 l/minute Liver diet III IVFD D5% gtt X/m (micro) Furosemide 2x40 mg Spironolacton 3x100mg Vit Bcomplex 3x1tab Ceftriaxon 1x1 gram Curcuma 3x1tab Clonidine 3x0,25

Because of her bulging abdomen, she sometimes felt shortness of her breath (dyspnea). Her dyspnea were not caused by her activities, emotional conditions, weathers, and never produced ngik sound. She still can sleep with one pillow, she never woke up in the middle of her night-time sleep because of short winded. She said sometimes she may had dark yellow or brown colored urine, but never passed black or bloody stools. Theres no others complaint in defecation and urination habits. She went to the local health care center and took some medicines (she didnt know name of drugs) but there was no improvement. 2 weeks before admission because of her abdomen seemed even more larger and tense, she had nausea and vomits, three times, containing all foods and fluids that she had been consumed that day. There was no blood in her vomit and no dark/bloody stools. Then, she was hospitalized in Moh. Hoesin Hospital in order to receive some better treatments. From physical examination we found: moderate sickness condition, vital sign within normal limit, nutrition state (in normal condition): IMT= 19,53 kgs/m2 (normoweight). There were pale of conjungtiva palpebrae (+), palmar erythema (+), icteric sclera (+), collateral vein (+), ascites (+).. The bulging of the abdomen in this patient was more specifically due to fluid accumulation in the peritoneal cavity. Because from physical examination we could see the bulging seemed to spread evenly in all region of the abdomen (frogs belly), tender in palpation, and had stony-dull sound. There was no palpable mass or tense and defans muscular in abdominal wall which is usually because of perforation/ peritonitis . The ascites because of kidneys diseases was stepped aside because there were no symptoms and signs being found. The patient were not experienced palpebrae edema when she woke up in the morning, nausea or vomit, itchs on skin, or any changed in urination habits (lessen in urines volume or frequency). On the other hands, fluid accumulation in patient with cardiovascular disorder usually observed at patients feet and ankle. The dyspnea is more severe, influenced by activities and better if patient take some rest (dyspnea on effort), orthopnea, paroxysmal nocturnal dyspnea can occur. So ascites in this case is more specific due to pathologic process in liver which is cirrhosis hepatic. Cirrhosis may cause no symptoms for long periods. The onset of symptoms may be insidious or, less often, abrupt. From anamnesis we knew that patient complain about felt weakness of her body, losing appetite, nausea, vomit (non-specific symptoms of compensated cirrhosis) and she had dark-yellow or brown coloured urine. In advanced cirrhosis, anorexia is usually present and may be extreme, with associated nausea and occasional vomiting. Abdominal pain may be present and is related either to hepatic enlargement and stretching of Glisson's capsule or to the presence of ascites.5 Physical examination, laboratory findings, and abdominal USG are very important in diagnosing cirrhosis hepatic.4 The stigmata of cirrhosis hepatic including erythema of palm, collateral vein, ascites, splenomegaly, icterus, and hypoalbuminemia are fulfilled in this patient. The single best test for diagnosing cirrhosis is biopsy of the liver. Liver biopsies, however, carry a small risk for serious complications, and, therefore, biopsy often is reserved for those patients in whom the diagnosis of the type of liver disease or the presence of cirrhosis is not clear.

CHAPTER III CASE ANALYSIS A sixty years old woman admitted to hospital on October 9th, 2009 with chief complaint bulging of the abdomen that became even larger since two weeks before admission. 2 months before admission, the patient complained about bulging of her abdomen, her bulging abdomen seemed to spread evenly so she found some difficulty in wearing her outfits. The patient felt uncomfort, heavy, and full of stomach that caused the decrease in her appetite, there was no constant pain on her abdomen. There was no nausea, vomiting, or fever. Her body became weak. In addition, both of her legs were swollen too, but she neither had the swelling eyelids especially when she woke up in the morning nor itching on her skin.

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Laboratory findings show anemia (Hb: 8,6 g/dl), trombocitopenia (175.000/mm3) due to both congestive splenomegaly as well as decreased thrombopoietin from the liver, hypoalbuminenia (2,1 g/dl): advanced cirrhosis leads to a reduced level of albumin in the blood and reduced blood clotting factors due to the loss of the liver's ability to produce these proteins. Bed rest: it is shown to inhibit the neurohomural system (RAAS and SNS) activated chronically in upright position in cirrhotic patients that impairs renal blood perfusion and causes sodium retention. Bed rest reduces the plasma aldosterone level and improves the response to diuretic therapy in cirrhotic patients. However, bed rest is not recommended routinely as it is often unpractical and could cause decubitus ulcers and muscle atrophy in malnourished cirrhotic patients6. Management of patients with cirrhosis and ascites. Generally, reduction of sodium intake is beneficial in patients with ascites. A low-sodium diet (60 to 90 mEq per day, equivalent to approximately 1500 to 2000 mg of salt per day) may facilitate the elimination of ascites and delay the reaccumulation of fluid.7,8 Two different schedules of diuretic treatment are used in cirrhotic patients with ascites. The most conservative schedule stars with spironolactone 100/mg day. If there is no response the dose is increased progressively to 200 mg/day and 400 mg/day. Furosemide is added at increasing doses (40, 80, and 160 mg/day) in patients not responding to 400 mg/day of spironolactone. In this patient we use the second strategy consists in the simultaneous administration of spironolactone and furosemide starting with 100 mg/day and 40 mg/day, respectively. If there is no response the dosages are increased to 200 mg/day and 80 mg/day and to 400 mg/day and 160 mg/day. Respectively there is a general agreement that these are the highest doses of diuretic to be used in cirrhotics. Weight loss should not go over 0.5 kg/day in the absence of edema and more than 1 kg/day in edematous state. 7,8 Clonidine (central agonist beta2 ) is used to decrease blood pressure and usually used to the resistance hypertension. The small dose of clonidine can used to treat hypertension without using a diuretic. All patients with ascites should be evaluated for transplantation, since the presence of ascites is associated with poor long-term survival (survival rate at five years, 30 to 40% vs. 70 to 80% among patients who have undergone transplantation).7 Fluid retention is the most frequent complication of End Stage of Liver Disease which is occurring in about 50% of patients within 10 years of the diagnosis of cirrhosis. It is associated with poor prognosis and 1-year and 5-year survivals of 85% and 56%, respectively.9

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