DEEP VEIN THROMBOSIS WITH SEPSIS AND HEPATITIS B

Ayuniza Harmayati 030.08.051

IDENTITY
Name : Mr. A Age : 18 years Gender : Men Address : Tegalwaru, Karawang Occupation : Student Religion : Islam Marital status : Not Married Race : Sundanese Education : Primary school Admission to hospital at July, 31th 2012

ANAMNESE
AUTOANAMNESE & ALLOANAMNESE

Main Complaint Abdomen pain in the right upper quadrant for the past 4 days, prior to admission.

Additional Complaint Swollen knee 2 days prior to admission. Nausea and vomitting 3 times/day Difficulty to pee and tea-coloured urine 1 week prior to hospitalization. Yellowing of the eyes.

History of Present Disease

Patient came to UGD RSUD Karawang with complaint of pain in the stomach region for the past 4 days. Vomiting and nauseated 3 days prior to admission. Patient has been vomiting 3 times/day, filled with food remnants. Patient also noticed his eyes was getting yellow. Patient complained that he has difficulty to pee, and his urine colour is like tea colour, 1 week prior to admission. Patient also complained of pain in the right knee for the past 2 days. Pain started after a football game 2 days ago, in which patient admit he was cramping throughout the game.

History of Present Disease

The pain is getting worse especially in the morning. The knee was started to swell and patient complained that it is hard to move, also is very painful when patient attempted to. 2 days after hospitalization, the swollen knee is getting bigger and worse. Patient complained that hes feeling very warm in the swollen right knee. 3 days after hospitalization, patient started to experience severe acute onset of shortness of breath(SOB). Patient relied heavily on oxygen. His right leg is completely swollen and warm, and is immobile because of the pain and the swollen knee. The pain in the stomach in the upper right quadrant is getting worse. On the night of the 3rd day, patient complained of fever and his SOB worsening, patient had to be moved to observation chamber in Rengasdengklok ward.

History of Past Disease

Hipertension () Asthma (-) Allergy (-) Liver disease (+)

Heart disease (-)

Kidney disease (-)

Maag (-)

Cancer (-)

Surgery (-)

Immobilitiation (-)

Fracture (-)

Spinal cord injury (-)

Stroke (-)

Family History
Same disease (-) Stroke (-) Cardiovascular (-)

DM (-)

Hypertension (-)

Liver disease (+) father

Cancer (-)

Kidney disease (-)

HABIT HISTORY
Not a smoker, not drinker, not a drug abuser. No routine medications. Like to play football so much, although occasionally having cramps.

PHYSICAL EXAMINATION

General condition
Appeareance : Severely ill

Consciousness : Compos mentis

Nutrition : Normal

Weight : 53kgs

Height : 160cms
BMI : 20,7

VITAL SIGN
Blood pressure: 120/60 mm Hg
Temperature: 39,4Oc

Respiration rate: 70x /mnt

Heart rate: 120x /mnt

Head Eyes Ears

Normochepaly, black hair, good distribution

Anemic conjungtiva -/-, Icteric sclera +/+

Hiperemic (-/-), tenderness (-/-), secrete (-/-)

Nose Mouth
Neck

Septum deviation (-), hiperemic concha (-/-), secret (-/-), mass (-/-), nostril breathing (-)

Red lip (+) dry (+). Carries (-) on M1-2 left and right. Tongue (N). Arcus faring (N). Tonsil (N). Posterior Pharyng (N)

Limf node: enlargement (-), tenderness (-) Thyroid: enlargement (-), tenderness (-) JVP: 5+1 cmH2O

THORAX
INSPECTION
Symetrical, deformation (-), intercostal retraction (-), substernal retraction (+)

PALPATION
Vocal fremitus equal, Ictus cordis on ICS V 1cm lateral left midclavicula linea, thrill (-), abnormal pulsation (-),

PERCUSSION
Sonor +/+, Lung Hepar Right Heart Lung Stomach Left Heart
: ICS V on right midclavicula linea : ICS 3-5 on 0,5 cm strenal linea : cannot Identifed : ICS 5 on 1cm medial left midclavicula linea

AUSCULTATION
HS I-II reguler, murmur (-), gallop (-) Vesicular breath sound +/+, ronchi -/-, wheezing -/-

ABDOMEN
INSPECTION Yellow-orange skin, symetrical, supple, flat Icteric (+) , Caput medusae (-), spider nevi (-) AUSCULTATION Bowel sound (+) , venous hum (-), arterial bruit on epigastric region (-) PERCUSSION Shifting dullnes (-) PALPATION Hepatomegali (+) 3 fingers from arcus costae and 1 finger from xiphoideus processus, blunt edge, makronodules (-), tenderness (+) Spleenomegali (-)

EXTREMITIES
Warm acral + + + +

Edema + Deformation (-), yellow-orange skin , spider nevi (-), palmar erythema (-), pale (-), icteric (+), flapping tremor (-) Right leg: swollen, warm, visible enlarged veins.

RESULT
1 Agustus 2012 Hb Leukosit Trombosit Ht Hitung Jenis -Basofil -Eosinofil -Batang -Segmen -Limfosit -Monosit GDS 10,2 g% 26.700 /ul 130.000 30 % 0 0 0 94 4 2 75 mg/dl

NORMAL RANGE
12 17 g% 5000 - 10000/ul 150.000 - 450.000 37 48 % 01% 13% 26% 40 70 % 20 40 % 28% 80 - 140 mg/dl

Ureum
Creatinin HbsAg

215 mg/dl
3.91 mg/dl -

10 - 45 mg/dl
0.4 - 1.5 mg/dl -

RESULT 1 Agustus 2012 Protein total Albumin Globulin Bilirubin Total Bilirubin Direct Bilirubin Indirect SGOT SGPT 5,52 3,69 1,83 6,8 6,14 0,66 91 54

NORMAL RANGE 6,5-8,5 mg/dL 3,5-5,0 mg/dl 2,6-3,6 mg/dl < 1,1 mg/dL < 0,6 mg/dL < 0,5 mg/dL < 40 u/L < 40 u/L

RESULT
Urine Warna Kuning, keruh

NORMAL RANGE

PH
Protein Reduksi

6,5
+1 -

Epitel
Leukosit Eritrosit

+
5-8 10-15

positif
0 5 / lpb 0 5 / lpb

Kristal
Silinder Bakteri

RESULT 4 Agustus 2012 Hb Leukosit Trombosit Ht GDS Ureum Creatinin 9,7 g% 31.400 /ul 143.000 29 % 82 mg/dl 84,1 mg/dl 1,01 mg/dl

NORMAL RANGE 12 17 g% 5000 - 10000/ul 150.000 - 450.000 37 48 % 80 - 140 mg/dl 10 - 45 mg/dl 0.4 - 1.5 mg/dl

RESULT
6 Agustus 2012 Hb Leukosit Trombosit 9,8 g% 36.800 /ul 173.000

NORMAL RANGE
12 17 g% 5000 - 10000/ul 150.000 - 450.000

Ht
D-Dimer

28 %
4.129,57 RESULT

37 48 %
< 500 mg/dl NORMAL RANGE 12 17 g% 5000 - 10000/ul 150.000 - 450.000 37 48 % 4 5 juta

9 Agustus 2012 Hb Leukosit Trombosit Ht Eritrosit 7,6 g% 25.600 /ul 879.000 22 % 3,14 juta

RESULT 13 Agustus 2012

NORMAL RANGE

Hb
Leukosit Trombosit Ht Ureum Creatinin

7,1 g%
18.700 /ul 1.218.000 21 % 56,2 mg/dl 0.55 mg/dl

12 17 g%
5000 - 10000/ul 150.000 - 450.000 37 48 % 10 - 45 mg/dl 0.4 - 1.5 mg/dl

Protein total
Albumin Globulin Bilirubin Total Bilirubin Direct Bilirubin Indirect SGOT SGPT

8,72
2,74 5,98 1,83 1,27 0,56 134 159

6,5-8,5 mg/dL
3,5-5,0 mg/dl 2,6-3,6 mg/dl < 1,1 mg/dL < 0,6 mg/dL

< 0,5 mg/dL

< 40 u/L < 40 u/L

RESUME
Anamnese
Physical examination
Eyes: Icteric sclera +/+ Swollen knee Nausea and vomitting Difficulty to pee and tea coloured urine

Mouth: Red lip (+) dry (+) Thorax: substernal retraction (+)
Abdomen: Yellow-orange skin, icteric (+), Hepatomegali Right leg: swollen, warm, visible enlarged veins

Yellowing of the eyes

Laboratory

Abdomen pain in the right upper quadrant

Hb: 10,2 g% Leukosit: 26.700 /ul Trombosit HbsAg: D-dimer: 4.129,57 SGOT / SGPT: Ureum : Bilirubin total, direct, indirect:

WORKING DIAGNOSIS
Deep Vein Thrombosis with Sepsis, AKI and Hepatitis B

Pulmonary embolism

Cellulitis

Baker cyst

DIFFERENTIAL DIAGNOSIS

Disseminated Intravascular Coagulation

trombophlebitis

TREATMENTTREATMENTS
Medicamentosa:
IVFD D 5% 10tpm Aminolebam 2x1 inj Ondansentron 3x1 inj Curcuma 3x1 Ceftriaxon amp 1x2gr Omeprazole amp 1x1 Pamol 3x1 Neurodex 1x1 Lovenox 0,6mg 2x1 Levofloxacin 1x1

SUGGESTED EXAMINATIONS
Coagulation test : APTT and TT (thrombin time) USG Doppler Venography Spiral CT angiography Anti HBs USG abdomen

Ad Sanationam : Dubia ad Malam

Ad Vitam :
Dubia ad Malam

Ad Fungsionam : Dubia ad Malam

PROGNOSIS