CBD

CASE BASE DISCUSSION

ISTIQOMAH
012085686
ADVISOR : DR. H. M. SAUGI ABDUH, SP.PD., KKV, FINASIM

Department of Internal Medicine

Medical School of Sultan Agung Islamic University
2017
Name : Mrs. S
Age : 71 y.o.
Gender : Female
Religion : Moslem
Job :-
Address : Bakalan 007/001, Kalinyamatan Jepara
MR number : 13226382
Room : Baitul Izzah 1 410.2
Entry date : August 31st, 2017
Date out : September 8th, 2017
HISTORY TAKING

History of Present Illness

Patient came to Islamic Hospital of Sultan Agung Semarang

Main Problem complain about her abdominal pain. Its started since a
month ago. abdominal pain is felt in the epigastric region.
The abdominal pain increases when the patient inhales. This
pain often felt periodically. Nausea and vomiting also

Abdominal pain complained by patient. Patient also complained about her

itchy skin. She felt this since she came to the hospital. Before
she came to this Hospital, she ever hospitalized in her city
with same complained. The doctor in that hospital delivered
the patient here for a better treatment.
HISTORY OF ILLNESS
HISTORY OF PREVIOUS ILLNESS
Hypertension history (-)
DM history (-)
Hepatitis history (-)
SOSIO-ECONOMIC HISTORY :
Hospital cost certified by
PBI

FAMILYS HISTORY OF DISEASE

Hypertension history (-)

DM history (-)
GENERAL STATUS
BMI (Body Mass Indeks)
Weight : 65 kg BMI= 65: (1,65 x 1,65) = 23,87 kg/m2
High : 165 cm
Interpretation :
Normoweight

General :
Awareness : Fully Aware / Compos Mentis (GCS=15)
Vital Sign
Blood Pressure : 110/60 mmHg
Heart rate : 90 x/minute
Breath Frequency : 24 x/minute
Temp : 36,5oC Interpretation :
Normal
GENERAL STATUS
Head : Mesocephal, alopesia (-)

Eyes : Anemic Conjuntiva(-/-), Icteric sclera(+/+)

Nose : symmetric, secret (-), Nostril Breath (-)

Ears : Normal Shape, discharge (-/-)

Mouth : Cyanosis (-), dry lips (-),

Neck : Trakhea deviation (-), Lymph Hypertropy (-)

Extremity : Oedem of lower extremity / upper extremity (-) / (-)

Interpretation : icteric sclera (+/+)

 PHYSICAL EXAMINATION
General : Neck : enlargement of the gland (-)
Chest : cough (-), sputum (-), blood (-)
Skin : eritematous (+),thick skuama (+)
Cardiac : chest pain (-), palpitations (-)
Head : headache (-) Digestive : abdominal pain (+), nausea (+),
Eyes : blurred vision (-), icteric sclera (+/+) vomiting (+)
Musculoskeletal : weak (-), rigid (-), back pain (-)
Ears : hearing loss (-), ring (-), discharge (-)
Extremity : oedem extremity (-)
Nose : nosebleed (-), discharge (-)

Mouth : cyanosis (-), thrush (-), bleeding gums (-)

Intepretation : eritematous skin (+), thick skin skuama
Throat : pain swallow(-), hoarseness (-), odinifagia (-) (+), abdominal pain (+), nausea vomiting (+)
 LUNG EXAMINATION
INSPEKSI ANTERIOR POSTERIOR

Static RR : 24x/min, Hyper pigment (-), spider nevi RR : 24x/min, Hyper pigment
(-), atrophy Pectoral Muscle (-), Hemithoraks D=S, ICS (-),spider nevi (-), Hemithoraks D=S,
Normal, Diameter AP < LL ICS Normal, Diameter AP < LL

Dynamic Up and down of hemitoraks D=S, abdominothorakal Up and down of hemitoraks D=S,
breathing, (-), muscle retraction of breathing (-), abdominothorakal breathing (-), muscle
retraction ICS (-) retraction of breathing(-),
retraction ICS (-)

Palpation Palpable pain(-), tumor (-), Arcus costae angle < 900, Palpable pain (-), tumor (-), Arcus costae angle <
enlargement of ICS (-), Stem fremitus D = S 900, enlargement of ICS (-), Stem fremitus D = S

Percution Sonor sonor

Auskultation Vesicular (+), Whezzing (-), Ronchi (-) Vesicular (+), Whezzing (-),
Ronchi (-)
Intepretation :
Normal
 CARDIAC EXAMINATION

Inspection : Ictus cordis isnt seen.

Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-),

sternal lift (-).

Percussion : dull sound

Upper borderline of heart : ICS II left sternal line
Waist of heart : ICS III left parastern line
Lower right borderline of heart : ICS V right sternal line
Lower left borderline of heart : ICS VI, 2 cm lateral linea mid clavcle sinistra
 ...CONT

Auscultation
Aortal valve : S1 & S2 standard, additional sound (-)

Pulmonary valve : S1 & S2 standard, additional sound (-)

Tricuspid valve : S1 & S2 standard, additional sound (-)

Mitral valve : S1 & S2 standard, additional sound (-)

Intepretation : Cardiomegali
 ABDOMEN EXAMINATION
Inspection : symetric, sycatric(-), striae(-),enlargement of vena (-),
caputmedusa (-).
Auscultation : peristaltic (+)
Palpation :
Superfisial : tight (-), mass (-), epigastrial pain (+)
Deep : abdominal pain (+), liver and kidney werent palpable, Murphys sign (+)
Percussion : tympani, side of deaf (-), shifting dullness (-)
Liver : right liver span 11 cm, left liver span 6 cm
Spleen : Throbe space percussion (-)

Intepretation : cholestasis
EXTREMITY EXAMINATION
Ekstremitas Superior Inferior

Oedema -/- -/-

Cold -/- -/-

Jaundice -/- -/-

Intepretation : Normal
LAB. EXAMINATION
Examination Result
(31/08/2017)
Hb 10,3 g/dl
Ht 28,7 % Intepretation :
Leukosit 6,00 ribu/uL Anemia
Trombositopenia
Trombosit 462 ribu/uL Bilirubin total, direk,
Ureum 25 mg/dl indirek
SGPT
Creatinin 0,66 mg/dl
SGOT
Bilirubin Total 19,92 mg/dl
Bilirubin Direk 15,11 mg/dl
Bilirubin Indirek 4,81 mg/dl
SGOT 84 U/I
SGPT 69 U/I
HbsAg kualitatif Non reaktif
LAB. EXAMINATION
Examination Result Examination Result
(04/09/2017) (04/09/2017)
Hb 8,4 g/dl Natrium 131,8 mmol/L
Ht 23,2 % Kalium 4,70 mmol/L
Leukosit 4,70 ribu/uL Chloride 93,5 mmol/L
Trombosit 373 ribu/uL Calcium 7,9 mmol/L
APTT/PPTK 26,6 detik
PPT 10,4 detik Intepretation :
GDS 80 mg/dl Anemia
Ureum 15 mg/dl
Proteinemia
Albuminuria
Creatinin 0,76 mg/dl Hyponatremi
Total protein 5,2 g/dl
Hypochloremi
Hypocalsemi
Albumin 2,77 g/dl
Globulin 2,48 g/dl
LAB. EXAMINATION
Examination Result
Examination Result
(06/09/2017)
(07/09/2017)
Hb 11,0 g/dl
Calcium 8,5 mmol/L
Ht 31 %
Leukosit 5,22 ribu/uL Intepretation :
Hipokalsemi
Trombosit 287 ribu/uL
Natrium 129,5 mmol/L
Kalium 4,43 mmol/L
Chloride 91,0 mmol/L
Calcium 8,1 mmol/L

Intepretation :
Anemia
Hiponatremi
Hipokloremi
Hipokalsemi
ECG
31/08/17
ECG 31/08/2017
IRAMA : Sinus rhytm
REGULARITAS : Regular
FREKUENSI : 83x/menit
AXIS : L1 (+) AVF (+) Normo Axis Deviation
ZONA TRANSISI :-
GELOMBANG P : 0,04 s
PR INTERVAL : 0,12 s
QRS COMPLEX : 0,12 s
ST SEGMEN : ST depresi di V1-V6
GELOMBANG T : T inverted di V1-V6

Intepretation :
RBBB incomplete
X-RAY THORAX
COR : Apeks bergeser ke laterokaudal.
Elongasi dan kalsifikasi arcus aorta.
PULMO:
Corakan vaskular tidak meningkat.
Tak tampak gambaran infiltrat.
Diafragma dan sudut kostofrenikus tak tampak
kelainan.
KESAN :
CARDIOMEGALI ( SUSPEK LV)
ELONGASI DAN KALSIFIKASI ARCUS AORTA
PULMO TAK TAMPAK KELAINAN
CT-SCAN ABDOMEN
CT-SCAN ABDOMEN
X-RAY THORAX
- Tampak pelebaran ductus bilier intra hepatal dan ekstra hepatal
HEPAR : Ukuran normal, tepi rata, densitas homogen, nodul (-)
vena porta, vena hepatica tak melebar, vena cava inferior tak melebar
LIEN : Ukuran normal, densitas homogen, nodul (-), vena lien tak melebar
KE : Dinding tak melebar, batu (-), sludge (-)
PANKREAS : Ukuran normal, massa kistik di capt pankreas uk 2.19 x 2.33 cm
GINJAL KANAN : Ukuran normal, pielocayses system tak melebarm batu (-), kista (-)
GINJAL KIRI : Ukuran normal, pielocayses system tak melebarm batu (-), kista (-)
VESICA URINARIA : Dinding tak menebal, batu (-), massa (-)
Tak tampak pembesaran limfonodi
KESAN : CHOLESTASIS INTRA HEPATAL DAN EKSTRA HEPATAL E.C KISTA CAPUT PANKREAS UK
2.19 X 2.33 cm
Abnormal Data

Radiology Examination
Ro Thoraks :
Physical Examination Lab Chemistry
9. Cardiomegali 12. Anemia
History Taking 5. Cardiomegali
ECG 13. Trombositopenia
1.Abdominal pain 6. Murphys sign (+) 14. Hyperbilirubinemia
10. RBBB incomplete 15. SGOT, SGPT
2.Itchy skin 7. Icteric sclera
CT-SCAN ABDOMEN : 16. Hypoalbuminemia
3.Nausea 8. eritematous skin (+),thick 17. Hyponatremi
11. Cholesistasis intra hepatal 18. Hypochloremi
4.Vomiting skuama (+)
dan ekstra hepatal e.C kista 19. Hypocalsemi

caput pankreas uk 2.19 x 2.33

cm
 PROBLEM LIST
1 2 3
HYPERBILIRUBINEMIA ANEMIA HYPONATREMI
(1, 2, 3, 4, 5, 6, 7, 8, 11, 14, 15) (12) (17)

4 5 6
HYPOCALSEMIA HYPOALBUMINEMIA RBBB INCOMPLETE
(19) (16) (10)
1. HYPERBILIRUBINEMIA
Ass :

Intrahepatal: hepatitis virus

Ekstra hepatal : ca caput pancreas

Ip Dx : gamma gt, alkali fosfatase, test serology hepatitis virus (anti

HAV, anti HCV, HCV RNA kualitatif, biopsi hati

Ca caput pancreas : ca19-9

1. HYPERBILIRUBINEMIA
Ip Tx :

Pharmacology :

Inj. Ranitidin 2x50 mg (1amp)

Ursodeoxicolicacid 2 x 1 cholestasis

Non Pharmacology :

Low fat intake

Consul to digestive surgery Ip.Ex :

Diet low fat
Ip. Mx : vital sign, bilirubin, transaminase Routine check of bilirubin
2. ANEMIA

Ass :
Hipokrom mikrositer anemia defisiensi Fe, anemia akibat penyakit kronis, thalassemia
Normokrom normositer anemia pasca perdarahan akut, anemia hemolitik, anemia akibat
penyakit kronis, anemia pada keganasan hematologi
Makrositer anemia defisiensi asam folat / B12
Ip. Dx :
Clinical sign of anemia, bleeding history, DR
Laboratorium darah
indeks eritrosit (MCV, MCH, MCHC)
hapusan darah tepi
Konsentrasi Besi Serum dan TIBC
Feritin Serum
Pemeriksaan sumsum tulang
Coomb test
Ip. Tx :
Pharmacology :
Sulfas Ferrosus 3 x 200 mg
Vitamin C 3 x 1

Ip. Mx :
Keadaan umum

Ip. Ex :
1. Menjelaskan pengertian dan sebab anemia
2. Menjelaskan untuk makan secara teratur
3. Memperbanyak menu yang dianjurkan
4. Menjelaskan untuk meminum obat yang diberikan secara teratur
3. HYPONATREMI

Ass :
Increase of amount fluid intake
Inability to suppress the ADH secretion sirosis hepatis, CHF

Ip. Dx : -

Ip. Tx :
Natrium correction 0,6 x 65 x (140 - 131,8) = 319,8 mEq/L

NaCl 0,9 % 2 flabot 1 flabot NaCl 0,9 % : Na 154 meq/L ; Cl 154 meq/L

Ip. Mx : vital sign, post correction electrolit

Ip. Ex : -
5. HYPOALBUMIN

Ass :
Etiology Penyakit hati (akut, kronis)
Ip. Dx : -
Ip. Tx :
koreksi albumin 0,8 x 65 x (3,5-2,77) = 17,16 gram
Albumin intake 20 % in 100 cc = 20 gr
Ip. Mx : Kadar albumin
Ip. Ex :
High albumin intake
6. RBBB

Ass :
Normal variant
Congenital heart disease ASD, VSD

Ip. Dx : ECG

Ip. Tx : -

Ip. Mx : ECG

Ip. Ex : -
4. HYPOCALSEMIA

Ass :
Vitamin D deficiency low fat intake
disturbed of vitamin D metabolism

Ip. Dx : -
Ip. Tx :
Calcium serum = 7,9 mg/dL 1,97 mmol/L

10 mL calcium gluconate 10 % in NaCl 0,9 % 1 ampul = 10 mL

Ip. Mx : Calsium level, ECG

Ip. Ex :
High calsium intake