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Case DR - Irwin
Case DR - Irwin
Anamnese
Patient was auto-anamnesed on Tuesday November 27th 2012 at 10.00 am
Patients Identity
Name Age Sex Address Occupation Religion Marital Status Race Education : Mrs. S : 45 years old : Female : Pancawati, Klari, Karawang :: Islam : Married : Sundanese : Junior High School
Chief Complaint
Additional complaints
Picture of Patient
3 months before, she complained her nails, until the whole body becomes yellow, but this time the whole body is not yellow anymore. Sometimes she had a fever, and nausea but never vomited blood. And her stool was black, also she had a dark urine, like tea color
History of treatment
She often went to the doctor at the local clinic for her disease and was given generic drugs She also went to an alternative medicine and was given herbal medicine for her symptoms But she didnt get better
Hypertension
(-)
Diabetes (-)
Malignancy (-)
Family history
Same symptoms (-) Food and drug allergy (-)
Hypertension (-)
Diabetes (-)
Malignancy (-)
Physical Examination
General Condition Appearance : moderately ill Consciousness: compos mentis Nutritional status: 152cm,40kg Abdominal circumference: 89 cm Vital Sign
Blood pressure: 90/70 mmHg Heart rate : 68x/min Respiration rate :20 x/min Temperature : 36,5C
Anemic conjuctiva +/+ icteric sclera +/+ Direct and indirect light reflexes +/+
Normotia, ear secretion -/- hyperemic -/- tragus pain -/auricula pain -/- intact tymphani membrane +/+
Red lip +, dry -, oral higiene +. Pharyngeal arc symetrical , tonsil T1-T1 innormal measure
Thoracal Examination-Heart
Inspection
Ictus cordis is invisible
PALPATION
Ictus cordis is palpable at 5th ICS LMCS
PERCUSSION
Right heart border : ICS III-IV LSD Left heart border : ICS V 1 cm medial LMCS Upper heart border : ICS III LPSS
AUSCULTATION
Reguler I-II absence of murmurs and gallop in hearts sound
Thoracal Examination-Lung
INSPECTION
Symmetrical in shape, spider navi -
PALPATION
Equal vocal fremitus
PERCUSSION
Sonor in both lungs
AUSCULTATION
Vesicular breathing sound in both lungs ronchi -/- wheezing -/-
Abdominal Examination
INSPECTION
Brown skin, distended, caput medusae -
PALPATION
pain +, undulation +, liver and lien are not palpable
PERCUSSION
pain on percution -, shifting dullness +
AUSCULTATION
Bowel sound +, arterial bruit -, Venous hum -
EXTREMITIY
+ Warm acrals
Oedem
LABORATORY EXAMINATION
Haematocryte
Basophil Eosinophil Neutrophyls Rod Neutrophyls Segment Limphocytes Monocytes
29 %
0% 0% 2% 70 % 25 % 5%
37-48 %
0-1 % 1-3 % 2-6 % 40-70 % 20-40 % 2-8 %
Laboratory Examination
Haematology HbsAg Result Normal Value -
Blood Sugar
Ureum Creatinin Total Protein Albumin Globulin Total Bilirubin Direct Bilirubin Indirect Bilirubin
95 mg/dL
36,8 mg/dL 1,27 mg/dL 6,41 mg/dL 2,68 mg/dL 3,73 mg/dL 3,51 mg/dL 2,76 mg/dL 0,75 mg/dL
80-140 mg/Dl
10-45 mg/dL 0,4-1,5 mg/dL 6,5-8,5 mg/dL 3,5-5,0 mg/dL 2,6-3,6 mg/dL < 1,1 mg/dL < 0,6 mg/dL < 0,5 mg/dL
SGOT
SGPT
128 mg/dL
203 mg/dL
< 40 mg/dL
< 40 mg/dL
LABORATORY EXAMINATION
Urine
Colour Clarity pH Protein Bilirubin Urobilin
Result
dark like a tea Not clear 6,0 -
Abdominal USG
Resume
History Taking
nausea weakness 3 months before, her nails, until the whole body becomes yellow consumes alcohol for 3 years
Physical Examination
abdominal circumference : 89 cm Anemic conjuctiva +/+ icteric sclera +/+ distended abdomen, ascites pain on epigastric +, undulation + shifting dullnes +
Laboratory Examination
anemia albumin globulin total bilirubin direct bilirubin indirect bilirubin SGOT SGPT dark urin black stool
Differential Diagnosis
Cirrhosis Hepatis ec Susp Alcoholic Hepatitis
Working diagnosis
Suggested Examination
Liver Biopsy
Esophagoscopy
Anti HcV
Protrombine time
Therapy (Medicamentosa)
Dextrose 5 % + Lasix 5 ampul 8
dpm Albumin 1 fl KSR 1X1 tab Ceftriaxon 2x1 amp Ranitidin 2x1 amp Omeprazole 1x1 amp Neurobion 1x1 tab Curcuma 3 x 1
Therapy (Non-medicamentosa)
Bed rest
Stop alcohol Stop consume jamu high protein diet
Prognosis