Case Report Session

Oleh:
Diah Ernita
Irfan Ghani Nasution
Ririn Syafitri Nasution

Preseptor: Dr. dr. Irza Wahid, SpPD-KHOM,

FINASIM
 Sirosis hepatis adalah akhir dari perjalanan klinis dari semua
penyakit hati kronis yang ditandai oleh distorsi arsitektur hati
dan pembentukan nodul regeneratif.
 Di seluruh dunia, prevalensi sirosis hepatis diperkirakan
mencapai 100 per 100.000 penduduk
 Laki-laki : wanita = 1,6 : 1
 Kelompok umur terbanyak adalah 30 – 59 tahun dengan
puncaknya sekitar umur 40-49 tahun.
 Penyebab sirosis hepatis sebagian besar adalah penyakit hati
alkoholik dan non alkoholik steatohepatitis serta hepatitis C
 Morbiditas dan mortalitas sirosis yang tinggi akibat
komplikasinya
 Sirosis merupakan stadium akhir dari penyakit hati kronik
setelah terjadinya fibrosis hati yang berlangsung progresif dan
ditandai dengan adanya kerusakan dari struktur hati dan
pembentukan nodulus regeneratif.

 Sirosis hepatis dibagi atas: sirosis hepatis kompensata dan

sirosis hepatis dekompensata yang ditandai dengan kegagalan
hepatoseluler dan hipertensi portal.
 Penyakit hati kronis dan sirosis merupakan penyebab nomor 6
kematian di Amerika Serikat pada individu yang berusia 25-44
tahun dan nomor 5 pada individu usia 45-64 tahun.
 Di RS Dr. Sardjito Yogyakarta ditemukan jumlah pasien
sirosis hepatis sekitar 4,1% dari pasien yang di rawat di
Bagian Penyakit Dalam pada tahun 2004.
 Di Medan ditemukan jumlah pasien sirosis hepatis
sebanyak 819 (4%) pasien dari seluruh pasien yang
dirawat di Bagian Penyakit Dalam selama empat tahun.
 Jumlah penderita sirosis hepatis di RSUP Dr. M Djamil
Padang ditemukan sebanyak 140 pasien dalam kurun
waktu September 2014 hingga Juni 2015.
 Di negara barat penyebab tersering dari sirosis
hepatis adalah akibat alkoholik.
 Di Indonesia penyebab sirosis hepatis terutama
disebabkan oleh infeksi virus hepatitis B maupun
hepatitis C.
 Virus hepatitis B menyebabkan sirosis sebanyak
40-50%, dan virus hepatitis C sebanyak 30-40%,
dan untuk sisanya 10-20% kasus penyebabnya
tidak diketahui dan termasuk kelompok virus
bukan hepatitis B dan C.
 Laporan Kasus

Identitas Pasien
Nama : Tn.K
No MR : 01043016
Jenis Kelamin : Laki Laki
Umur : 57 tahun
Pekerjaan : Guru
Status Perkawinan : Menikah
Agama : Islam
Alamat : Padang
Tanggal Masuk : 16-03-2019
Keluhan Utama :
Perut membuncit
dan semakin membesar
sejak 2 minggu yang lalu
sebelum masuk rumah sakit
 Riwayat Penyakit Sekarang
Riwayat Penyakit Sekarang:
- Perut membuncit dan semakin
membesar sejak 2 minggu yang lalu
sebelum masuk rumah sakit
-Pasien merupakan rujukan dari RSUD
Bangko dalam keadaan kaki
membengkak dan luka dikaki dan
mendapat obat insulin intravena da
juga tablet
-BAK seperti teh pekat ada, BAB
dempul tidak ada
Sesak nafas meningkat sejak 3 hari
yang lalu
-Demam ada sebelum masuk rumah
sakit, demam tidak terlalu tinggi
-Riwayat DM ada sejak 7 bulan yang
lalu, kontrol tidak teratur
-Luka dikaki kanan dan kiri sejak 1
minggu yang lalu
-Sembab pada tungkai kanan ada
-Riwayat BAB berdarah atau berwarna
hitam seperti aspal (-).
-Riwayat penyakit kuning disangkal.
-Mual (-), muntah (-), riwayat muntah
darah (-)
Riwayat Penyakit Dahulu:
Riwayat DM ada tidak terkontrol
Riwayat penyakit jantung tidak ada
Riwayat sakit kuning disangkal
Riwayat HT disangkal

Riwayat Penyakit Keluarga:

Tidak ada anggota keluarga yang
memiliki keluhan yang sama dengan
pasien
Tidak keluarga yang menderita penyakit
hipertensi, DM dan penyakit jantung.

Riwayat Kebiasaan, Sosial, dan Ekonomi:

Pasien seorangguru olahraga SMP
Pasien seorang perokok dengan IB berat
Riwayat alkohol disangkal.
Riwayat penggunaan jarum suntik,
berhubungan seks sesama jenis dan
seks bebas disangkal.
Tato tidak ada.
Pemeriksaan Fisik
Pemeriksaan Umum
Keadaan umum : sakit sedang
Kesadaran : komposmentis
kooperatif
Tekanan darah : 120/80 mmHg
Nadi :81x/menit
Pernapasan :20x/menit
Suhu :36,5oC
Keadaan gizi : Sedang
Sianosis : tidak ada
Ikterus : ada
Edema : ada
Anemis : tidak ada
Kulit :
Infographic Style
teraba
hangat, turgor kulit normal,
terdapat bercak bercak Toraks :
bekas luka, spider naevi (-), Paru :
KGB : tidak ada Inspeksi : bentuk
pembesaran KGB normochest,
Kepala : simetris kiri =
normocephal kanan secara
Rambut : hitam, dinamis dan statis
tidak mudah dicabut Palpasi : fremitus
Mata : kiri = kanan
konjungtiva Content Perkusi : sonor
anemis, sklera ikterik (+/+), Title Auskultasi :
Telinga : tidak ada Here
vesikuler, ronkhi -
kelainan /-, wheezing -/-
Hidung : tidak ada
kelainan
Tenggorok :
tidak ada kelainan
Gigi dan mulut :
tidak ada kelainan
Leher : JVP 5-2
cm H2O
Jantung
Inspeksi: iktus kordis tidak
terlihat
Palpasi : iktus kordis teraba 1 jari
medial LMCS RIC V
Perkusi :batas jantung kiri iktus kordis
batas jantung kanan LSD
batas jantung atas RIC II
Auskultasi : S1-S2 irama
regular, murmur tidak ada, S3 Gallop (-)
Abdomen :
Inspeksi: tampak membuncit
Palpasi : hepar teraba, lien tidak
teraba,
Perkusi : undulasi (+)
Auskultasi : bising usus (+)
normal
Punggung
Inspeksi: tidak ada deformitas
Palpasi : nyeri tekan (-)
Perkusi : nyeri ketok CVA (-)
Genitalia : tidak diperiksa
Anus : tidak diperiksa
Ekstremitas : Palmar eitem
: +/+
 Asites

Education
Plan

Edem tungkai Ulkus pedis

 Pemeriksaan Penunjang
 Infographic Style

Darah(18/03/2019) :
PEMERIKSAAN PENUNJANG Hb 15,0 gr/dL (N:
Pemeriksaan Laboratorium 13-16 gr/dL)
Darah (16/03/2019) : Hb 13,7 gr/dL (N: 13-16 gr/dL) Leukosit 15.110/mm3 (N:
Leukosit 12.310/mm3 (N: 5000-10.000/mm3)
5000-10.000/mm ) 3
Hematokrit 42% (N:
Hematokrit 41% (N: 40- 40-50%)
50%) Trombosit 307.000/mm3
Trombosit 339.000/mm3 (N: 150.000-450.000/mm3)
(N: 150.000-450.000/mm3) PT : 11,9,0
Ureum 167 (N:10,0- APTT : 39,2
50,0) Kesan : Leukositosis
Kreatinin 5,9 (N :0,8- PT& APTT
1,3) melebihi nilai rujukan
Na 129 mmol/L (N: 136- Kimia Klinik :
145 Mmol/L) (19/03/2019) Ureum 218
K 6,5 mmol/L (N: 3,5- (N:10,0-50,0)
5,1 Mmol/L) Creatinin 6,3
CI 105 mmol/L (N:97- (N :0,8-1,3)
111 Mmol/L) Na 133 mmol/L (N:
Albumin 2,1(N:3,8-5,0 g/dl) 136-145 Mmol/L)
Globulin 14,5 (N:1,3- K 5,3 mmol/L
2,7 g/dl) (N: 3,5-5,1 Mmol/L)
CI 107 mmol/L
(N:97-111 Mmol/L)
Urinalisis(18/3/19) : Warna cokelat
Kekeruhan (+)
pH 5,0
Eritrosit (350-400)
Leukosit (3-4)
Silinder (-)
Kristal (-)
Sel epitel (+) gepeng
Protein positif +++
Glukosa (negatif)
Bilirubin (+++)
Urobilinogen (+)
Kesan : Bilirubin +++
Hematuria
Proteinuria
 Infographic Style

Diagnosis Diagnosis Banding

Sirosis hepatis post Asites ec keganasan
necrotic std Hepatoma Rencana
dekompesanta Tapping asites
DM tipe II tidak Tatalaksana
terkontrol O2 3L/menit
Ulkus Pedis (D) Infus comafusin hepar :
Trombositopenia ec triofusin : NaCl 0,9% 1 : 1
SH : 1, 8 jam/kolf
Hipoanatremia Inj Ceftazidime 2x1
Inj levofloxacin 1x750
Inj metronidazole 3x500
Bic Nat 3x500
As folat 1x5
Spironalakton 1x150
Lactulac syrup 3x 2 cth
Propanolol 1x10
N ace 3x1
PCR 3x500
Bolus 10 unit insulin
D40% + inj Ca glukonas
Follo
w Up
FOLLOW UP
20/03/2019 :
S/ sadar (+)
Sesak berkurang
Perut membuncit (+)
O/ KU/sdg KES/cmc TD/110/80 ND/76
NF/20 T/af
Mata : Konjungtiva tidak anemis
Sklera Ikterik +/+
JVP 5-2 cmHg
Abdomen : Asites +, Shifting dullness + BU(+)N
Ext : edema +/+
A/ Sirosis hepatis post necrotic std dekompesanta
DM tipe II tidak terkontrol
Ulkus Pedis (D)
Trombositopenia ec SH
Hipoanatremia
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