ACUTE VIRAL HEPATITIS B

Anggita Nur Aziza

*
*
Name : Mr. Y
Age : 45 y.o
Sex : Male
Address : Sukajaya Kampung
Pinayungan RT 14 RW 06
Kecamatan Teluk Jambe Timur
Kabupaten Karawang
Occupation : Computer Labour
Religion : Muslim
Marital status : Married
Date of addmision : October 23
rd
2011
Taken from : Rengasdengklok
Pain in upper right abdomen
since 2 days before
hospitalized
Chief
complaint
Fever
Nausea and vomitting
Aches from back waist to
feet
Hasnt been defecated for 2
days
Additional
complaint
*
*Patient came with pain in upper right abdomen
since 2 days before hospitalized. It felt sharp,
continously, not radiating and day by day is
getting worse especially when the patient lying
down.
*Beside the pain, the patient also felt aches
from back waist to feet, nausea and vomitting,
and fever.
*Fever starts from 2 days before hospitalized, intermittent.
*Nausea and vomitting starts from 2 days before hospitalized,
vomitted about 2 times, food in its contain, blood (-)
*The aches from back waist felt since 1 days before
hospitalized, sharp, continously, worsened when the patient
is walking and sit down.

*Theres no pain and no dripping when he is urinating. The
patient hasnt been defecated since 2 days before
hospitalized. He also loss his appetite and loss weight since a
month ago.
*Dizziness, fatigue, cough, pain in chest are denied.
*Lately, patient said that the pain in abdomen and back waist
is decreased. But the patient feel shortness of breath since
last night, and swollen in his feet.
*
Same
condition (+)
Hypertension
(-)
Diabetes
mellitus (-)
Cardiovasular
(-)
Kidney (-) Allergy (-)
*
Same
condition (-)
Hypertension
(-)
Diabetes
mellitus (-)
Cardiovasular
(-)
Kidney (-) Allergy (-)
Had gone to puskesmas
2 days before
hospitalized and get
medicated
Herbal medicine (-)
Blood transfusion (+)
PAST MEDICAL
HISTORY
*
Smoke (-)
Alcohol (-
)
Tattoo (-)
Free sex
(-)
Narcotics
(-)
Injection
drugs (-)
He didnt
exercise
regularly
*
Severely ill
General
appearance
Compos
mentis
Conciousness
Vital
Sign
BP:
130/70
mmHg
RR:
24x/min
Temp:
37,5
0
c
HR:
120x/min
*
Head
Normocephaly
Eyes
Conjunctiva anemic -/-
Sclera icteric -/-
Ears
Normotia
Secret -/-
Serumen -/-
Nose
Sepeum deviation -
Secret -/-
Concha normal
Mouth
Dirty mouth -
Dry mouth -
Dry tongue -
Throat
Tonsils T1/T1
Faring hiperemis (-)
Neck
Lymph gland is not palpable
Thyroid gland is not palpable
JVP 5+2 cm
Inspection:
Symmetrical
Palpation:
Equal vocal fremitus
Percusion:
Sonor in both lung
Auscultation:
Vesicular breath sound in both
lung, no ronchi and wheezing
Inspection:
Ictus cordis is invisible, spider
nevi (-)
Palpation:
Ictus cordis is palpable at 5
th
ICS
LMCS
Percution:
no enlargment
Auscultation:
Regular I - II heart sound no
murmur and gallop

*
*
Inspection
Brown skin, bulging abdomen, icteric (-), caput meducae (-)

Palpation
Pain present on palpation at right hypochondrium region
Liver palpable 3 fingers under arcus costae, soft consistency, sharp
edge, flat surface, tenderness (-)
Spleen palpable at Schuffner 4, soft consistency, sharp edge, flat
surface, tenderness (-)
Shifting dullness (-)

Percussion
No pain present on abdominal percussion
Dullness
CVA (-)

Auscultation
Bowel sound (+). Arterial bruit (-), venous hum (-)

*
*Warm acrals





*Oedema
+ +
+ +
+ -
+ +
*
October 23rd 2011 Patient result Normal range
Hb 8.00 % 12 17 g%
Leukocyte 5.100/uL 5000-10.000/uL
Trombocyte 227.000 150.000-450.000
Ht 24 % 37-48 %
HbsAg + -
GDS 105 mg/dl 80-140 mg/dl
Ureum 66,2 mg/dl 10-45 mg/dl
Creatinine 1.39 mg/dl 0.4-1.5 mg/dl
Albumin 3,10 3.5-5.0 mg %
SGOT 56 < 40 u/l
SGPT 36 < 40 u/l
*
October 24th 2011 Patient result Normal range
Protein total 6,05 mg% 6.5 8.5 mg%
Albumin 3,22 mg% 3.5 5 mg%
Globulin 2,83 mg% 2.6 3.6 mg%
Total Bilirubin 0,68 mg/dl < 1.1 mg/dl
Direct Bilirubin 0,37 mg/dl < 0.6 mg/dl
Indirect Bilirubin 0,31 mg/dl < 0.5 mg/dl
SGOT 650 u/l < 40 u/l
SGPT 429 u/l < 40 u/l
*
October 25th
2011
Patient result Normal range
Ureum 33.3 10-45 mg/dl
Creatinin 1.30 0.4-1.5 mg/dl
*
Symptoms Signs Laboratory and others
Pain in upper right
abdomen
Fever
Nausea and vomitting
Aches form back waist
untill feet
Hasnt been defecated
for 2 days
Loss of appetite
Weight loss
Shortness of breath
Swollen in feet

Vital sign:
BP: 130/70 mmHg
HR: 120 x/min
RR: 24 x/min
T: 37.5
0
c

Abdomen:
Bulging abdomen
Hepatomegali and
splenomegali
sounds dull


Hb: 8.0 g%
Ht: 24 %
HbsAg: +
Ureum: 69 mg/dl
Creatinine: 1.94 mg/dl
Protein total : 6.05 %
Albumin: 3.10 mg%
Globulin: 2.83 mg%
Total bilirubin: 0.68 mg/dl
Direct bilirubin: 0.37
mg/dl
Indirect bilirubin: 0.31
mg/dl
SGOT: 650 u/l
SGPT: 429 u/l
*
1. Acute viral hepatitis B
2. Chronic hepatitis B
3. Acute non viral hepatitis B
4. Cirrhosis hepatis
5. Cholelithiasis
*
Acute viral hepatitis B
*
*Imunoserologic examination
*USG
*Urinalysis
*Liver biopsy

*
*IVFD RL 20 tpm
*IVFD Aminofusin hepar
*Ranitidin 2 x 1 amp
*Curcuma 3 x 1 tab
*Meloxicam 1 x 15 mg
*Alprazolam 1 x 0.5 mg
*Neurodex 2 x 1 tab
*Laxadin 2 x C II
*
Ad
fungsionam
: dubia ad
malam
Ad sanationam
: dubia ad
malam
Ad vitam :
dubia ad
bonam