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    Case Report: Hepatitis B

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    dewi sartika
    This case report describes a 15-year-old male patient presenting with fatigue who has a history of hepatitis B. On examination, the patient was in moderate pain but otherwise stable. Laboratory tests found the patient's liver and kidney function to be normal. The patient tested positive for HBeAg and was diagnosed with chronic hepatitis B virus infection. He was prescribed an antiviral medication and will undergo further monitoring of liver enzymes and viral markers. The prognosis will depend on the patient's condition and response to treatment.

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    Case Report: Hepatitis B

    Uploaded by

    dewi sartika
    310 views34 pages
    This case report describes a 15-year-old male patient presenting with fatigue who has a history of hepatitis B. On examination, the patient was in moderate pain but otherwise stable. Laboratory tests found the patient's liver and kidney function to be normal. The patient tested positive for HBeAg and was diagnosed with chronic hepatitis B virus infection. He was prescribed an antiviral medication and will undergo further monitoring of liver enzymes and viral markers. The prognosis will depend on the patient's condition and response to treatment.

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    This case report describes a 15-year-old male patient presenting with fatigue who has a history of hepatitis B. On examination, the patient was in moderate pain but otherwise stable. Laboratory tests found the patient's liver and kidney function to be normal. The patient tested positive for HBeAg and was diagnosed with chronic hepatitis B virus infection. He was prescribed an antiviral medication and will undergo further monitoring of liver enzymes and viral markers. The prognosis will depend on the patient's condition and response to treatment.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    310 views34 pages

    Case Report: Hepatitis B

    Uploaded by

    dewi sartika
    This case report describes a 15-year-old male patient presenting with fatigue who has a history of hepatitis B. On examination, the patient was in moderate pain but otherwise stable. Laboratory tests found the patient's liver and kidney function to be normal. The patient tested positive for HBeAg and was diagnosed with chronic hepatitis B virus infection. He was prescribed an antiviral medication and will undergo further monitoring of liver enzymes and viral markers. The prognosis will depend on the patient's condition and response to treatment.

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    Division of Gastroenterology-hepatology

    Department of Internal Medicine


    Hasanuddin University Medical School

    CASE REPORT
    Hepatitis B

    Division of Gastroenterology-hepatology | Department of Internal Medicine | Hasanuddin University Medical School


    PATIENT IDENTITY

    • Name : Mr. M

    • Date of Birth : 31 – 08 – 2003

    • Gender : Male

    • Address : Makassar

    • Medical Report Number : 876121


    HISTORY
    • Chief complaint : Easily fatigue

    • Present illness : 15 year old boy come to the hospital for control
    with complaints of fatigue. There was no fever, no seizures, no coughing,
    no chest tightness and no jaundice. The child is lost of appetite, defecation
    is normal and brown in color, urination is normal and yellow in color.
    History of jaundice was approximately 2 months ago. Hospitalized and the
    screening test with reactive HBsAg result and HBV-DNA 9,6x104.
    Patient has a history of mothers with Hepatitis B positive since 2016.
    PHYSICAL EXAMINATION

    • General examination : patient is in moderate pain, conscious


    and cooperative (GCS15). He is in good nutritional status and
    his hydration status is adequate.
    Wight: 50kg, Height: 164cm.
    VITAL SIGN

    • Temperature : 36,8°C

    • Blood pressure : 90/60mmHg

    • Pulse rate : 84 beats/minute (regular rhythm)

    • Respiratory rate : 20 breaths/minute (vesicular)


    HEAD

    • Shape : Normocephal

    • Face : Symmetrical left and right

    • Deformity : None

    • Hair : Difficult to removed


    EYES
    • Eksoftalmus/Enoptalmus : (-)
    • Movement : Normal
    • Eyelids : Edema (-)
    • Conjungtiva : Anemis (-)
    • Sclera : Jaundice (-)
    • Cornea : Clean
    • Pupil : Isokor
    EARS

    • Tophi : (-)

    • Hearing : Normal
    NOSE

    • Bleeding : (-)

    • Mucus : (-)
    MOUTH
    • Lip : Cyanosis (-), Dry (-)

    • Tooth : Caries (-)

    • Gum : Bleeding (-)

    • Tonsils : T1-T1 hiperemis (-)

    • Farings : Hiperemis (-)

    • Tounge : Dirty (-)


    NECK

    • Lymph node : No lymphadenopathy

    • Thyroid : No enlargement thyroid

    • Blood vessel : Normal

    • Stiff neck : (-)


    THORAX

    • Inspection : Symmetrical left and right

    • Palpation : Right focal fremitus is the same as left

    • Percussion : Sonor

    • Auscultation : Vesicular, rhonchi (-), wheezing (-)


    HEART

    • Inspection : No ictus cordis

    • Palpation : No thrill

    • Percussion : Normal

    • Auscultation : Reguler, no murmur


    ABDOMEN

    • Inspection : Flat

    • Auscultation : Peristaltik (+), normal

    • Palpation : Tenderness (-), massa (-), hepar and lien not


    palpable

    • Percussion : Tympany (+)


    BACK

    • Inspection : Symmetrical

    • Palpation : Right focal fremitus is the same as left,


    tenderness (-)

    • Percussion : Sonor, flank pain (-)

    • Auscultation : Vesicular, ronchi (-), wheezing (-)


    EXTREMITY

    • Edema (-)

    • Clubbing finger (-)

    • Warm hand and feet (+)


    LABORATORIUM
    KIDNEY FUNCTOIN NORMAL
    Ureum 12 10-50mg/dL
    Creatinine 0,60 <1,3mg/dL
    LIVER FUNCTION
    SGOT/AST 32 <38U/L
    SGPT/ALT 28 <41U/L
    IMMUNOSEROLOGY
    Albumin 4,3 3,5-5,0gr/dL
    HBeAg 0,01/Non Reactive <0,1 COI
    Anti-HBe 0,02/Reactive >=0,5/Non Reactive COI

    SUPPORTING EXAMINATION : Fibroscan 5,5 F0-F1


    ASSESSMENT

    Hepatitis B Virus Infection


    PLANNING
    Treatment Curliv syrup 5ml/24H/oral

    Blood routine, SGOT/SGPT,


    Examination plan Ureum, Creatinine, HBeAg,
    Bilirubin total and direct
    PROGNOSIS
    Depending on the patient's condition at the time of arrival, the
    presence or absence of complications and treatment
    Discussion
    Hepatitis B Virus

    HBV : liver infection caused by the hepatitis B virus. HBV can cause and liver
    infections. Incubation period: 75 days (around 30-180 days). The hepatitis B virus
    can survive outside the body for at least 7 days. During this time, the virus can still
    cause infection if it enters the body of a person who is not protected by the
    vaccine. The virus may be detected within 30 to 60 days after infection and can
    persist and develop into chronic hepatitis B.
    HBV Transmission
    Infected blood products : Spread by percutaneous
    recipient of blood products, or mucosal exposure to
    hemodialysis (HD) patients, various body fluids:
    health worker, job exposure saliva, menstrual,
    to blood vaginal, and seminal
    fluids

    Sexual transmission

    Infected items such as


    needles, razor blades,
    dental or medical
    equipments.
    Serological Markers of HBV infection
    Classification
    Symptoms
    Icteric phase :
    • weight loss
    • Sclera icteric
    Konvalesens :
    Acute HBV • Dark urin
    • Hepatomegali (+)
    physical examination :
    • Abnormal liver
    • Hepatomegaly
    chemical examination
    • tenderness in the
    right quadrant area
    above the abdomen

    • Asymptomatic
    • Acute HBV
    symptoms
    • liver cirrhosis
    Laboratory

    • HBV serological test/imunoserologi (serological markers of HBV)


    • Liver biochemistry test (SGOT, SGPT, bilirubin, albumin, globumin,PT,
    GGT, alkali fosfatase) ;
    • USG, liver biopsy, Fibroscan
    Diagnosis
    Acute Hepatitis Infection :
    • History of HBV infection
    • HBsAg (-)
    • Serum HBV DNA is not
    detected
    • ALT normal
    Treatment
    Peg-Interferon:
    • Peg-IFN-2a: 180 ug/SC
    • Peg-IFN-2b: 1.15 ug/KgBB/week.SC
    Analog Nukleosida:
    • Lamivudin: 100 mg/day.PO
    • Telbivudin: 600 mg/day.PO
    • Entecavir: 0.5-1 mg/day.PO
    Analog Nukleotida:
    • Adefovir: 10 mg/day.PO
    • Tenofovir: 300 mg/day.PO
    Thankyou

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