January 16th, 2016

 Initial : NA
 Sex : male
 Age : 34 years old
 Religion : Hindu
 Ethnic : Bali
 Marital Status : Not married
 Address : Bangli
 Time of arrival : January 15th, 2016 (3 p.m)
Chief Complaint: yellow on both eyes

 Patient complain yellow on both eyes since 12

day BATH, getting worse with spread to his face
and body
 During 1 day before starting the yellow eyes,
patient has history fever, but not so high.
Patient didn’t measure the temperature.
Patient didn’t take any medication.
 From that day until now, patient complain
weakness and pain on right upper stomach
 Decrease of the body weight was denied by
patient.
 the urine become yellow-brown like tea at
the same time with yellow eyes
 the defecation was normal as usual. Yellow-
brown in colour. History pale of the feces
was denied.
 History of hepatitis, diabetes mellitus,
hypertension, asthma, heart disease, tumor
or malignacy was denied
 History of drug and food allergy was denied
 History blood transfusion (-), operation (-)
 There is no history of the same complain with
patient in his family.
 There is no history of the hepatitis in his family
 History of hypertension, Diabetes mellitus, heart
disease, asthma, malignancy was denied by
patient.
 Patient is a farmer. Patient isn’t married
yet, but he claimed to have sexual
intercourse with several women.
 Patient also have tattoos since 1 year ago.
 He said that he didn’t drink alcohol, but he
smoke 1 pack everyday.
Present status:
 General condition : moderately ill
 Consciousness : E4V5M6
 Blood pressure : 120/80 mmHg
 Pulse rate : 86 beat/minute
 Resp. rate : 18 times/minute
 Axillary temp. : 37o C
 Body weight : 70 kg
 Height : 171 cm
 BMI : 23,9 kg/m2
 General Status
 Eye : anemic -/-, icterus +/+, pupillary reflexes
+/+ isokor
 ENT : Tonsil Normal, Pharing: no redness, gland
swelling (-)
 Neck : JVP 0 cm H2O, gland enlargment (-)
 Thorax : symmetrical
Cor : I : ictus cordis unseen
Pal : ictus cordis unpalpable
Per : UB : ICS II
RB : right PSL
LB : left MCL
Aus: S1S2 Single Regular, Murmur(-)
Lung: I : Symetrical
Pa : VF N/N
Per : sonor on both lung
Aus : ves +/+, wh-/-, rh-/-
 Abdomen : I : Distension (-)
Aus : Bowel sound normal
Pal : Liver/spleen unpalpable
pain on palpation (VAS 2/10)
in right upper quadrant.
Murphy sign (-)

Per : Tympany(+), flank pain -/-

Extremeties : Warm + + Edema - -

+ + - -
  Complete Blood Count January 15th 2016
Parameter Result Unit Reference Range

WBC 8,25 103/μL 5,2 – 12,4

-Ne 4,85 58,8 % 103/μL 1,9 – 8
-Ly 2,2 26,68 % 103/μL 0,9 – 5,2
-Mo 0,95 11,46 % 103/μL 0,16 – 1,2
-Eo 0,13 1,61 % 103/μL 0,0 – 0,5
-Ba 0,12 1,45% 103/μL 0,0 – 0,2
RBC 5,27 106/μL 4,00 – 5,4
HGB 15,82 g/dL 12,00 – 16,00
HCT 49,3 % 36,0 – 47,0
MCV 93,57 fL 80,0 – 100,0
MCH 30,03 pg 26,0 – 34,0
MCHC 32,1 g/dL 31,0 – 36,0
PLT 200,1 103/μL 150 – 440
  Blood Chemistry Panel

Parameter Result Unit Remarks Reference Range

SGOT 966,7 U/L H 0 – 33,00
SGPT 932,6 U/L H 0 – 50,00
BUN 5 mg/dL L 8 – 23,00
Creatinine 0,64 mg/dL L 0,70 – 1,20
Bilirubin direct 20,74 mg/dL H 0,0-0,3
Bilirubin indirect 6,45 mg/dL H 0-0,8
Bilirubin total 27,19 mg/dL H 0,30-1,30
Albumin 3,49 g/dL 3,4-4,8

Random blood glucose 72 mg/dL 70 – 140

Na 136 mmol/L 136-145

K 3,74 mmol/L 3,5-5,1
Alkali phospatase 112 U/L 53-128
Gamma GT 91 U/L H 7-32
Globulin 4,23 g/dL H 3,2-3,7
Total Protein 7,72 g/dL 6,4-8,3
 Cor:CTR 48%
 Pulmo: nodul(-),
infiltrat (-),
broncovaskular
pattern normal
 Left and right sinus
pleura are sharp
 Left and right
diafragma is normal
 Conclusion:
cor&pulmo normal
 No radioopaque stone
 Conclussion: normal
Normal Sinus Rhythm
HR 73x/minute
Normal axis
Susp acute viral hepatitis B
 Hospitalized
 IVFD NaCl 0,9% 20 dpm
 Diet 2100 kkal
 Curcuma 3x1 tab io
 Paracetamol 3x500mg io if fever
- IgM anti HAV
- HBsAg
- IgM anti HCV
- USG Abdomen
 Vitalsign
 Patient Complaints