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    Skenario B Blok 15

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    Guszaldo HP
    Mr. E, a 38-year-old man, presented to the emergency department with yellow eyes for the past 3 days. He also reported dark tea-colored urine, mild fever for 1 week, weakness, epigastric pain, nausea, and decreased appetite. He was born with hepatitis B, as were his mother and brother. On examination, he had scleral icterus, pretibial edema, and palmar erythema. Laboratory tests found elevated bilirubin and liver enzymes. The primary problem appeared to be acute exacerbation of chronic hepatitis B.

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    Skenario B Blok 15

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    Guszaldo HP
    134 views10 pages
    Mr. E, a 38-year-old man, presented to the emergency department with yellow eyes for the past 3 days. He also reported dark tea-colored urine, mild fever for 1 week, weakness, epigastric pain, nausea, and decreased appetite. He was born with hepatitis B, as were his mother and brother. On examination, he had scleral icterus, pretibial edema, and palmar erythema. Laboratory tests found elevated bilirubin and liver enzymes. The primary problem appeared to be acute exacerbation of chronic hepatitis B.

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    Mr. E, a 38-year-old man, presented to the emergency department with yellow eyes for the past 3 days. He also reported dark tea-colored urine, mild fever for 1 week, weakness, epigastric pain, nausea, and decreased appetite. He was born with hepatitis B, as were his mother and brother. On examination, he had scleral icterus, pretibial edema, and palmar erythema. Laboratory tests found elevated bilirubin and liver enzymes. The primary problem appeared to be acute exacerbation of chronic hepatitis B.

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    Download as docx, pdf, or txt
    134 views10 pages

    Skenario B Blok 15

    Uploaded by

    Guszaldo HP
    Mr. E, a 38-year-old man, presented to the emergency department with yellow eyes for the past 3 days. He also reported dark tea-colored urine, mild fever for 1 week, weakness, epigastric pain, nausea, and decreased appetite. He was born with hepatitis B, as were his mother and brother. On examination, he had scleral icterus, pretibial edema, and palmar erythema. Laboratory tests found elevated bilirubin and liver enzymes. The primary problem appeared to be acute exacerbation of chronic hepatitis B.

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    of 10

    SKENARIO

    Mr. E 38 years old, came to the emergency department with complaint of yellow eyes in the
    last 3 days. The complaint was accompanied by urine that looks like dark tea, no history of
    putty-like stool and itchy skin. Patient has been having mild fever in the last 1 week. Mr. E also
    complained weakness of the body, epigastric pain, nausea and decreased appetite.

    Mr. E had hepatitis B from birth, his mother and his brother, had hepatitis B too. Mr. E had no
    history of long-term medication, consumption of alcohol, and drugs abused.

    Physical Examination

    General condition: moderate illness, compos mentis

    Vital Sign: BP 120/80 mmHg, pulse 90x/min, RR 20x/min, temperature 37,2 celcius

    Weight 54 kg, height 160 cm

    Specific Examination

    Head: Palpebra conjunctiva was not pale, sclera was yellow (+/+)

    Neck: JVP 5-2 cmH2O, lymph nodes were not palpable

    Thorax:

    Thoracic wall: Spider nevi was evident

    Pulmo:

    - Inspection: Symetrical, static, and dynamic


    - Palpation: Right and left stem fremitus were the same
    - Percussion: Overall pulmonary field was sonor
    - Auscultation: Vesicular breathing sound (+/+), rhonci (-/-), wheezing (-/-)
    Cor:

    - Inspection: Flat, Apex beat was not visible


    - Palpation: Apex beat not palpable
    - Percussion: Normal heart limit
    - Auscultation: HR 80x/min, regular, heart sounds I-II normal
    Abdomen:

    - Inspection: Flat, caput medusa (-), cullen sign (-), gray turner sign (-)
    - Palpation: Weak, Murphy sign (-), liver not palpable, lien S2, ballottement(-)
    - Percussion: Shifting dullness (+)
    - Auscultation: Normal Bowel sound
    Extremities: Pretibial edema (+), Palmar Erythema (+)

    Laboratory examination:

    - Hb: 12,3 g/dL


    - Ht: 36 vol%
    - Leukosit: 8.600/mm3
    - Platelet: 90.000/mm3
    - LED: 70mm/hour
    - Bil tot: 8,2 mg/dL
    - Bil direk: 7,6mg/dl
    - Bil Indirek: 0,6mg/dl
    - SGOT: 102u/L
    - SGPT: 115u/L
    - Alkaline Phosphatase: 110u/L
    - Anti HAV IgM (-)
    - HbsAg (+)
    - Anti HCV (-)
    - Albumin 2,8mg/dL
    1. Klarifikasi Istilah
    i. Hepatitis B: penyakit viral akut yang terutama ditularkan secara parenteral melalui
    kontak personal yang erat atau dari ibu ke neonates, gejala berupa demam, maleis,
    anoreksia, mual, dan muntah, mereda seiring munculnya gejala icterus, angioderma,
    lesi kulit ulikarial, dan artritis.
    ii. Urine that looks like dark tea:
    iii. Anti HCV: antibodi terhadap virus hepatitis C, terdapat dalam darah,
    mengindikasikan infeksi hepatitis C atau kronis.
    iv. Putty-like stool: feses berwarna seperti dempul.
    v. HBs Ag: kompleks antigen yang ditemukan pada permukaan virus hepatitis B.
    vi. Ballottement: Teknik palpasi pada dinding abdomen ketika ginjal didorong secara
    paksa dari belakang. Hal ini untuk mendeteksi adanya ginjal yang mengapung.
    vii. Lien S2: pembesaran lien yang teraba pada arcus costae sinistra.
    viii. Bilirubin direct: bilirubin yang telah diambil oleh sel-sel hati dan dikonjugasikan
    membentuk bilirubin biglukuronin yang larut dalam air.
    ix. Bilirubin indirect: bentuk bilirubin larut lemak yang beredar dalam asosiasi longgar
    dengan protein plasma.
    x. Alkaline phosphate: grup enzim yang dihasilkan oleh hepar, tulang, usus, plasenta,
    dan ginjal di tubulus proksimal. ALP meningkat dalam plasma pada keadaan
    obstruksi saluran empedu, kolestatik intrahepatic, sirosis hepatis, fatty liver, tumor
    hepar, hepatitis, dan intoksikasi obat.
    xi. Gray-turner sign: tanda memar pada sisis bagian tubuh antara tulang rusuk terakhir
    dan bagian atas pinggul, merupakan tanda pendarahan retroperitoneal dan biasanya
    pada serangan pankreatitis akut yang parah.
    xii. Murphy sign: pemeriksaan yang dilakukan seorang dokter kepada pasien untuk
    menentukan adanya kolelitiasis atau kolesistitis dengan menggunakan ibu jari atau
    telunjuk yang diletakkan antara tepi kanan m. rectus abdominis dan arcus costae,
    pasien melakukan inspirasi bila merasakan sakit maka hasil (+).
    xiii. Caput medusa: dilatasi vena cutaneous di sekitar umbilicus, biasanya terlihat pada
    pasien sirosis hepatis.
    xiv. Palmar erythema: manifestasi klinis sirosis hepatis dari berbagai penyebab. Palmar
    eritema merupakan palmar yang menjadi kemerahan karena kongesti pembuluh
    darah kapiler.
    xv. Shifting dullness: suatu tanda yang mengarah pada pemeriksaan fisik untuk ascites.
    xvi. Pretibial edema: edema pada bagian anterior tungkai bawah sampai tibia.
    xvii. Anti-HAV IgM: diagnosis serologis dari fase infeksi virus hepatitis A.
    xviii. SGOT: serum glutamite oxaloacetic transaminase yang merupakan enzim yang
    normal, terdapat pada sel hepar dan sel jantung, dikeluarkan ke darah jika terjadi
    kerusakan hepar atau jantung.
    xix. SGPT: serum glutamite pyruvic transaminase merupakan enzim yang normal
    terdapat pada sel hepar dan sel jantung, dikeluarkan ke darah jika terjadi kerusakan
    hepar atau jantung.
    xx. Rhonchi:
    xxi. Wheezing:
    xxii. Palpation: weak:

    2. Identifikasi Masalah

    Fakta Ketidaksesuaian Prioritas

    Mr. E 38 years old, came to the emergency VVVVV


    department with complaint of yellow eyes in the last
    3 days.

    The complaint was accompanied by urine that looks VVVV


    like dark tea, no history of putty-like stool and itchy
    skin. Patient has been having mild fever in the last 1
    week. Mr. E also complained weakness of the body,
    epigastric pain, nausea and decreased appetite.
    Mr. E had hepatitis B from birth, his mother and his VVV
    brother, had hepatitis B too. Mr. E had no history of
    long-term medication, consumption of alcohol, and
    drugs abused.

    Physical Examination VV

    General condition: moderate illness, compos mentis

    Vital Sign: BP 120/80 mmHg, pulse 90x/min, RR


    20x/min, temperature 37,2 celcius

    Weight 54 kg, height 160 cm

    Specific Examination VV

    Head: Palpebra conjunctiva was not pale, sclera was


    yellow (+/+)

    Neck: JVP 5-2 cmH2O, lymph nodes were not


    palpable

    Thorax:

    Thoracic wall: Spider nevi was evident

    Pulmo:

    - Inspection: Symetrical, static, and


    dynamic
    - Palpation: Right and left stem fremitus
    were the same
    - Percussion: Overall pulmonary field was
    sonor
    - Auscultation: Vesicular breathing sound
    (+/+), rhonci (-/-), wheezing (-/-)
    Cor:
    - Inspection: Flat, Apex beat was not
    visible
    - Palpation: Apex beat not palpable
    - Percussion: Normal heart limit
    - Auscultation: HR 80x/min, regular, heart
    sounds I-II normal
    Abdomen:

    - Inspection: Flat, caput medusa (-), cullen


    sign (-), gray turner sign (-)
    - Palpation: Weak, Murphy sign (-), liver
    not palpable, lien S2, ballottement(-)
    - Percussion: Shifting dullness (+)
    - Auscultation: Normal Bowel sound
    Extremities: Pretibial edema (+), Palmar
    Erythema (+)

    Laboratory examination: VV

    - Hb: 12,3 g/dL


    - Ht: 36 vol%
    - Leukosit: 8.600/mm3
    - Platelet: 90.000/mm3
    - LED: 70mm/hour
    - Bil tot: 8,2 mg/dL
    - Bil direk: 7,6mg/dl
    - Bil Indirek: 0,6mg/dl
    - SGOT: 102u/L
    - SGPT: 115u/L
    - Alkaline Phosphatase: 110u/L
    - Anti HAV IgM (-)
    - HbsAg (+)
    - Anti HCV (-)
    - Albumin 2,8mg/dL
    Alasan prioritas masalah: Keluhan pertama menyebabkan pasien datang ke rumah
    sakit dan merupakan sebuah kegawatdaruratan

    3. Analisis Masalah
    1. Mr. E 38 years old, came to the emergency department with complaint of yellow eyes
    in the last 3 days.
    a. Bagaimana anatomi dan fisiologi dari hepatobilier? (vania, rafi, aldo)
    b. Apa penyebab dan bagaimana mekanisme dari jaundice pada kasus? (rafi, aldo,
    bella)
    c. Apa saja etiologi dari terjadinya jaundice? (bella, afiya, icha)
    d. Apa makna keluhan mata kuning sejak 3 hari pada kasus? (afiya, icha, ale)

    2. The complain was accompanied by urine that looks like dark tea, no history of putty-
    like stool and itchy skin. Patient has been having mild fever in the last 1 week. Mr. E
    also complained weakness of the body, epigastric pain, nausea and decreased appetite.
    a. Bagaimana patofisiologi urin berwarna seperti teh pekat? (icha, ale, intan)
    b. Bagaimana interpretasi no history of putty-like stool and itchy skin? (ale, intan,
    alif)
    c. Bagaimana ciri-ciri urin dan feses yang normal? (intan, alif, peksi)
    d. Bagaimana patofisiologi mild fever pada kasus? (peksi, safira, sandora)
    e. Bagaimana patofisiologi weakness of the body pada kasus? (safira, sandora,
    vania)
    f. Bagaimana patofisiologi epigastric pain pada kasus? (sandora, vania, rafi)
    g. Bagaimana patofisiologi mual dan penurunan nafsu makan pada kasus? (vania,
    rafi, aldo)

    3. Mr. E had hepatitis B from birth, his mother and his brother, had hepatitis B too. Mr.
    E had no history of long-term medication, consumption of alcohol, and drugs abused.
    a. Apa saja faktor risiko dari penyakit hepatitis B? (rafi, aldo, bella)
    b. Apa saja komplikasi dari penyakit hepatitis B? (aldo, bella, afiya)
    c. Bagaimana patofisiologi dari penyakit hepatitis B? (bella, afiya, icha)
    d. Bagaimana hubungan penyakit hepatitis B dengan keluhan yang dialami pasien?
    (afiya, icha, ale)
    e. Bagaimana tatalaksana pengobatan penyakit hepatitis B? (icha, ale, intan)

    4. Physical Examination
    a. Apa interpretasi pemeriksaan fisik pada kasus? (ale, intan, alif)
    b. Bagaimana mekanisme abnormalitas pemeriksaan fisik pada kasus? (intan, alif,
    peksi)
    c. Mengapa seminggu yang lalu pasien mengalami mild fever tetapi terjadi
    perbaikan suhu pada pasien? (alif, peksi, safira)

    5. Specific Examination
    a. Apa interpretasi pemeriksaan spesifik pada kasus? (peksi, safira, sandora
    b. Bagaimana mekanisme abnormalitas pemeriksaan spesifik pada kasus? ? (safira,
    sandora, vania
    c. Bagaimana cara pemeriksaan shifting dullness? (sandora, vania, rafi)

    6. Laboratory examination:
    a. Apa interpretasi pemeriksaan laboratorium pada kasus? (vania, rafi, aldo)
    b. Bagaimana mekanisme abnormalitas pemeriksaan laboratorium pada kasus? (rafi,
    aldo, bella)

    HIPOTESIS

    Mr. E, laki-laki 38 tahun, diduga menderita sirosis hepatis decompensata et causa


    hepatitis B.

    a. Apa algoritma penegakan diagnosis dari kasus? (icha, ale, intan)


    b. Apa saja diagnosis banding pada kasus? (ale, intan, alif, icha)
    c. Apa diagnosis kerja pada kasus? (intan, alif, peksi, icha)
    d. Apa definisi penyakit pada kasus? (alif, peksi, safira)
    e. Bagaimana etiologi dari penyakit? (peksi, safira, sandora)
    f. Bagaimana epidemiologi dari penyakit? (safira, sandora, vania)
    g. Bagaimana klasifikasi dari penyakit? (sandora, vania, rafi)
    h. Bagaimana patogenesis dan patofisiologi dari penyakit? (vania, rafi, aldo)
    i. Bagaimana manifestasi klinis dari penyakit? (rafi, aldo, bella)
    j. Bagaimana pemeriksaan fisik pada kasus? (aldo, bella, afiya)
    k. Bagaimana pemeriksaan penunjang pada kasus? (bella, afiya, icha)
    l. Bagaimana tatalaksana (kajian, informasi, dan edukasi) dari penyakit pada kasus?
    (afiya, icha, ale)
    m. Apa saja komplikasi dari penyakit pada kasus? (icha, ale, intan)
    n. Bagaimana prognosis dari penyakit ini? (ale, intan, alif)
    o. Apa SKDI dari penyakit pada kasus? (intan, alif, peksi)

    Kerangka Konsep
    4. Learning Issue
    a. Sirosis hepatis
    b. Hepatitis B
    c. Anatomi, fisiologi hepatobilier

    Kesimpulan

    Mr. B, 30 tahun mengidap infeksi tuberculosis paru dengan BTA positif dan limfadenitis TB.

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