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    Acute Viral Hepatitis B Anggita Nur Aziza

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    Anggita Nur Aziza
    This document describes a case of a 45-year-old male patient presenting with acute viral hepatitis B. The patient reports pain in the upper right abdomen, fever, nausea, vomiting, back and leg pain, loss of appetite, weight loss, and shortness of breath. A physical exam finds hepatomegaly and splenomegaly. Laboratory tests show elevated liver enzymes and the presence of HBsAg, consistent with acute hepatitis B. The patient is given IV fluids and medications to manage symptoms as the viral infection runs its course.

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    Acute Viral Hepatitis B Anggita Nur Aziza

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    Anggita Nur Aziza
    39 views28 pages
    This document describes a case of a 45-year-old male patient presenting with acute viral hepatitis B. The patient reports pain in the upper right abdomen, fever, nausea, vomiting, back and leg pain, loss of appetite, weight loss, and shortness of breath. A physical exam finds hepatomegaly and splenomegaly. Laboratory tests show elevated liver enzymes and the presence of HBsAg, consistent with acute hepatitis B. The patient is given IV fluids and medications to manage symptoms as the viral infection runs its course.

    Original Description:

    Hepatitis B

    Original Title

    CASE 1

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    This document describes a case of a 45-year-old male patient presenting with acute viral hepatitis B. The patient reports pain in the upper right abdomen, fever, nausea, vomiting, back and leg pain, loss of appetite, weight loss, and shortness of breath. A physical exam finds hepatomegaly and splenomegaly. Laboratory tests show elevated liver enzymes and the presence of HBsAg, consistent with acute hepatitis B. The patient is given IV fluids and medications to manage symptoms as the viral infection runs its course.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    39 views28 pages

    Acute Viral Hepatitis B Anggita Nur Aziza

    Uploaded by

    Anggita Nur Aziza
    This document describes a case of a 45-year-old male patient presenting with acute viral hepatitis B. The patient reports pain in the upper right abdomen, fever, nausea, vomiting, back and leg pain, loss of appetite, weight loss, and shortness of breath. A physical exam finds hepatomegaly and splenomegaly. Laboratory tests show elevated liver enzymes and the presence of HBsAg, consistent with acute hepatitis B. The patient is given IV fluids and medications to manage symptoms as the viral infection runs its course.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 28

    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

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