case veta vellicia

7/27/2019 Case Veta Vellicia

1/10

PRESENTATION CASE

INTERNAL MEDICINE DEPARTEMENT

Supervisor :dr. Katharina Setyawati Sutrino, Sp. PD

Presented by :

FELISITAS (2011.061.184)

VILETTA FITRIA SAVATWINI (12100112041)

SMF ILMU PENYAKIT DALAM

RSUD R. SYAMSUDIN, SH

2013


2/10

I. PATIENT IDENTITYName : Mr. A

Age : 56 years old

Address : Kp. Citatah Rt.002/021, Sukabumi

Occupation : Retired

Ethnic : Sunda

Education : Elementary School

Religion : Moslem

Status : Married

Admission : April 30th 2013

Date of Examination : May 01st 2013

II. ANAMNESISAutoanamnesis

Chief complaint:

Swelling in both lower limbs 3 days before admission

Additional complaint :

Patients complain the whole body and both eyes look yellow, pain in epigastrium,

nausea

HISTORY TAKING

PRESENT ILLNESS

3 days before admission, the patient complained of swelling in both lower

limbs felt heavy and every time it runs.The patient also complained of pain in the

gut such as tingling and does not spread to other parts of the abdomen. 1 month

before admission, the patient felt a yellow discoloration of the skin on the hands

and feet as well as in both eyes.This complaint is accompanied with nausea but no

vomiting. Sometimes patients feel the fever is not too high for 1 month.

Patients also complain every time urination, urine brown, gritty urine denied

by the patient. Defecation sometimes diarrhea within 1 month. Patients feel less

appetite. Stomach feels bloated.Shortness of breath, cough and colds denied by the

patient.Complaints of itching of the skin is denied by the patient.


3/10

PAST ILLNESS

The patient had a history of yellowing of the entire body of 1 years ago.Patients cured with herbal medicines in the village

A history of dyspepsia (+)

Denied a history of hypertension Denied a history of diabetes mellitus Denied a history of heart disease Denied a history of allergyHABITUAL HISTORY

Smoking habit since I was a teenager until now.

In one patient a day could spend a pack of cigarettes. Coffee drinking habits Irregular eating habits and snack at random Denied a history of alcohol drinking by patients History of blood transfusion denied by the patientDenied a history of injecting drug use by patients

FAMILY HISTORY

History of diseases with similar symptoms denied History of hypertension and diabetes mellitus in family members refuted by

patients

Denied a history of heart diseaseIII.PHYSICAL EXAMINATION

Weight : 60 kg

Height : 160 cm

BMI : 23.43 kg/m2

General condition : Looks moderate sick

Awareness : Compos Mentis

Blood pressure : 120/80 mmHg

Pulse : 72 x / min

Respiratory rate : 20 x / min

Axilla temperature : 36.90 C

General condition : Looks moderate sick

Awareness : Compos Mentis


4/10

HEAD & FACE

Head : Normocephali, deformity (-)

Hair : Black, not easily removed

Eyes : CA - / -, SI + / +,pupil isokor 3mm/3mm

Ear : Inflammation - / -, secretions - / -, wax - / -

Nose : Septum nasi middle, secretions - / -

Mouth : oral mucosa hyperemia, coated tongue -, Frenulum jaundice (+)

NECK

Trachea in the middle, does not seem lesion or other skin lesions, the KGB was

not palpable

Thoracic-Lung

I: Symmetrical under static and dynamic conditions, retractions between the ribs

-, spider nevi

P: Motion symmetrical palpable breath, stem fremitus left = right

P: Sonor in both lung fields, lung-liver border in ICS 5 midclavicularis dextra

A : vesicular breath sounds + / +, rhonki - / -, wheezing - / -

Cardio-thoracic

I: Ictus cordis invisible

P: Ictus cordis ICS V palpable in the left linea midclavicularis

P: Upper limit : ICS II linea parasternalis the left

Right boundary : ICS V linea sternal dextra

Left boundary : ICS V linea midclavicularis the left

A: I and II heart sound regular, gallop (-), murmur (-)

BACK

I: Motion breath symmetrical, do not look deformed

P: symmetric breathing motion, stem fremitus left = right

P: Sonor on the right and left backs

A: Vesicular breath sounds + / +, rhonki - / -, wheezing - / -


5/10

ABDOMINAL

I: Convex, mass (-), sikatriks (-)

P: Supple, tenderness (+) in the gut, defans (-), murphy sign (-)

P: Thympany throughout the quadrant

A: Bowel (+ ) 3-4 times / minute

Extremity

Upper extremity:

-Eutrofi, normotonus, akral warm, CRT


6/10

WIDAL TESTEXAMINATION DATED MAY 1ST, 2013:

O TO: 1/320O TH: 1/320


7/10

O AH: 1/60O BH: 1/320

SEROLOGYEXAMINATION DATED MAY 1ST , 2013:

O HBSAG: (-)O ANTIHCV: (-)

2. ABDOMINAL ULTRASOUND

RESULT OF USG ABDOMEN

CHRONIC LIVER DISEASE MINIMAL ASCITES GALLSTONE (-)


8/10

V, PROBLEM LIST

1. Jaundice2. Edema of both lower legs3. Dyspepsia4. Tea-colored urine

VI.WORKING DIAGNOSIS

o Icterus obstructive et causa sirosis hepatico Thyphoid fever

VII.Suggestions Examination

o Amilase, lipaseo HbeAgo Thoraks PA Rontgento CT scan abdomen

VIII. DIFFERENTIAL DIAGNOSTIC

o Chronic hepatitiso Acute Pankreatitiso Cholelithiasiso Cholesistitiso Leptospirosis

IX. CASE STUDY

1. Obstructive icterusEnforced through:

Anamnesa

1 month before admission, the patient felt a yellow discoloration of theskin on the hands and feet as well as in both eyes.

This complaint is accompanied with nausea but no vomiting.

Patients complain of tea-colored urineA history of jaundice 1 years ago


9/10

Physical Examination

Eye : sclera jaundice +/+

Mouth : Frenulum jaundice (+)

Extremities : skin looks yellow on the upper and lower extremities

2. Sirosis hepatic

Anamnesa

3 days before admission, the patient complained of swelling in both lowerlimbs felt heavy and every time it runs.

Patients feel less appetite. Stomach bloating, nausea (+) Subfebris fever (+) Tea-colored urine

Investigations

SGOT> SGPT Hypoalbunemia Hyperbilirubinemia Abdominal ultrasound: minimal ascites, hepatic cirrhosis picture

3. THYPOID FEVER

Anamnesa

The patient also complained of pain in the gut such as tingling and does notspread to other parts of the abdomen.

Defecation sometimes diarrhea within 1 month's time.WIDAL TEST

TO: 1/320

TH: 1/320

AH: 1/60

BH: 1/320

X. TREATMENT

Non-PharmacologicalBed rest

Low-salt diet (5.2 g or 90 mmol / day)


10/10

PharmacologicalInfusion aminofusin: futrolit = 1: 1 (20 TPM)

Spironolacton 1x 100 mg tab

Curcuma 2x200mg tab

Ondansetron 2x8 mg IV

Urdahex 3x1 tab

Child-Pugh Classification

XI. PROGNOSIS

Quo ad vitam : dubia at bonam

Quo ad fungsionam : dubia at bonam

Quo ad sanationam : dubia at malam

case veta vellicia

Documents