CASE BASED DISCUSSION

Disusun Guna Memenuhi Salah Satu Tugas Kepaniteraan Klinik

Program Pendidikan Profesi Dokter Bagian Ilmu Penyakit Dalam
Di Rumah Sakit Islam Sultan Agung Semarang

Disusun oleh:
Muhammad Ulil Albab
01.210.6228
Pembimbing:
dr. Lusito, Sp.PD

BAGIAN ILMU PENYAKIT DALAM

FAKULTAS KEDOKTERAN UNIVERSITAS ISLAM SULTAN AGUNG
SEMARANG
2015
CASE REPORT

A. Patient`s Identity
Name

: Mr. I

Age

: 62 y.o

Sex

: Male

Religion

: Moslem

Job

: Unemployed

No. Medical Record : 012.58.778

Address

: Dadapsari, semarang

Room Care

: Baitul Izzah 1

Date in

: July, 15th 2015

Date out

: July, th 2015

Status Care

: JKN Non PBI

B. Data
1. Anamnesis
Main Problem : Hard breathing
o History of Present Illness
Patient came into the emergency department of Islamic Hospital of
Sultan Agung Semarang complained about her abnormal breathing
and chest pain like kneaded since a few days ago. Its started last 2
days in the middle of her sleep. She was awakened because lack of
breath and had cold sweat.
o History of previous illness

Hypertension history

(-)

Heart disease history

(+)

DM history

(-)

Asthma

(-)

Smooking

(+)

o Familys history of disease

Hypertension history

(-)

DM history

(-)

o Sosio-Economic History :

Hospital cost certified by JKN NON PBI

C. Systemic Anamnesis
o General

: weak

o Skin

: itching (-), jaundice (-), pale (-)

o Head

: headache (-)

o Eyes

: blurred vision (-), red eyes (-), icteric sclera (-/-)

o Ears

: hearing loss (-), discharge (-)

o Nose

: nosebleed (-), discharge (-)

o Mouth

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

o Throat

: pain swallow(-), hoarseness (-), difficult in

swallowing (-)
o Neck

: enlargement of the gland (-), nape pain (-)

o Chest

: cough (-), sputum (-), blood (-), dyspnea (+)

o Cardiac

: chest pain (+), palpitasions (-)

o Digestive

abdominal pain (-) at the

upper right region, decreased appetite (-),

nausea (-), vomiting (-), defecate/micsi (+/+)
o Musculosceletal : weak (-), rigid (-), back pain (-)
o Extremity

: oedem inferior extremity (-)

D. Physical Examinations
General Status

General

: Dyspneu

Awareness

: composmentis

Head

: Mesocephal, alopesia (-)

Eyes

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

Nose

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

Ears

: Normal Shape, discharge (-/-)

Esophagus

: Hyperemic (-), pain devour (-)

Mouth

: Cyanosis (-), dry lips (-)

Neck

: Trakhea deviation (-), Lymph Hypertropy

(-), JVP <2cm

Extremity

: Oedem of lower and upper extremity (-)

Vital Sign
o Blood Pressure

: 140/90 mmHg

o Heart rate

: freq. 80 x/minutes

o Breath Frequency

: 32x/minutes

o Temp

: 36,2o C

a. PF thorax
Pulmo:
INSPEKSI

ANTERIOR

Static

RR

POSTERIOR
32x/min,

Hyperpigmentation

(-),

tumor

(-),

tumor (-), inflammation

inflammation

(-),

(-),

(-),

spider

nevi

(-),

spider

D=S,

SIC

Hemithorax D=S, SIC

Normal, Diameter AP <

Normal, Diameter AP

LL

< LL

Hemithorax

Dinamic

(-),

Hyperpigmentation

hemithorax
D=S

movement

nevi

hemithorax movement
D=S

Palpation

Palpation pain (-), tumor

Palpation

(-),

ICS

tumor (-), normal ICS,

(-),

Stem fremitus increase

normal

enlargemnet of ICS
Stem

fremitus

increase

pain

(-),

D=S

D=S
Percussion

Dull (+)

Dull (+)

Auscultatio

Vesicular (+)

Vesicular (+)

ronchi

ronchi

(+/+), wheezing

(-/-)

(+/+),

wheezing (-/-)

Cor :

Inspection

: Ictus cordis isnt seen.

Palpation
: Ictus cordis was palpable at ICS VI 2 cm
lateral linea mid clavicula sinistra,

thrill (-),

pulsus

epigastrium (-), pulsus para-sternal (-), sternal lift (-).

Percussion
: dull sound
Upper borderline of heart
:
ICS II linea sternalis
sinistra
Waist of heart

: ICS IV linea parasternalis

sinistra
Lower right borderline of heart

dextra
Lower left borderline of heart

: ICS V, 2 cm lateral linea

ICS IV linea sternalis

mid clavicula sinistra

Auscultation
Aorta valve
: S1 & S2 standart, additional sound (-), AI
< A2
Pulmonal valve

: S1 & S2 standart, additional sound (-), P1

< P2
Trikuspidal valve

: S1 & S2 standart, additional sound (-), T1

> T2

 Mitral valve

: S1 & S2 standart, additional sound (-), M1

> M2
b. Abdomen
Inspection

: symetric, sycatric(-), striae(+), enlargement

of vena (-), caput medusa (-)

Auscultation : peristaltic (+)

Palpation

Superfisial

: tight (-), massa (-)

Deeper : abdominal pain (-), hepar not palpable, lien
not palpable, Murphys sign (-)

Percussion

: tympany, side of deaf (-), shifting dullness (-)

Hepar : deaf (+), liver span dextra 11 cm, liver span sinistra 6 cm

Lien : troube space percussion (+) tympani

c. Extremities
Extremity

superior

inferior

- Oedem

-/-

-/-

- cold extremities

-/-

-/-

- Physiological reflex

+/+

+/+

-/-

-/-

- Icteric

E. Laboratory`s Examination
HEMATOLOGY

Hemoglobin

Hematokrit: 42,1 %

Leukosit

Trombosit : 324 ribu/ uL

Blood Group

: B (+)

Troponin I ultra

: 21,67 ug/L

: 13,8 g/dl

: 24,8 ribu/uL

KIMIA

GDS

: 141 mg/dl

Ureum

: 38 mg/dl

Natrium

: 131,5 mmol/l

Kalium

: 4,55 mmol/l

Chloride

: 98,2 mmol/l

Creatinine : 1,22 mg/dl

Calcium

: 8,9 mg/dl

F. Radiology
1. Chest X-ray

Interpretation:
o Cardiomegaly (LVH)
o Bronkhopneumoni duplex

2. ECG

Interpretation :
o STEAMI
o VT Non sustained
G. Data of Abnormality
Anamnesis:

Hard breathing

weak

Physical Examination :

Chest dullnes

Ronchi (+)

Stem fremitus increase dextra = sinistra

Cardiomegaly

Advance Examination:
Laboratory:
-Natrium: 131,5 mmol/l (L)
-Leukosit: 24,8 ribu/uL (H)
-blood glucose:141 mg/dl(H)
-Creatinin : 1,22 mg/dl
(H)
-troponin I ultra: 21,67 ug/L (H)
X-ray:
Cardiomegaly (LVH)
Bronkhopneumoni duplex
ECG:
STEAMI
VT non susteined
H. Problem List
1. STEAMI
2. Bronchopneumonia duplex
3. Hiperglikemia
4. Hiponatremia
I. Discussion
1. STEAMI
Ass :
IP Dx :
IP Tx:
o Aspilet 80 mg 1x1
o Clopidogrel 1x75mg
o Atorvastatin 1x20mg

o ISDN 5 mg sub ling

o Bisoprolol 2,5 mg
o Morfin
o Heparin (anti koagulan)
IP Mx : ECG
IP Ex:
Tell patient and his family about his illness
Bed Rest/Restriction of physical activity
Sodium & Fluid `restriction
Reducing Emotional stress
Calory restriction in overweight patient
Sit position or setengah tidur
2. Bronchopneumonia Duplex
Ass : pneumonia, Lung Tuberculosis
IP Dx : sputum test, x foto thorax
IP Tx:
Ceftriaxon 2 gr 1x1
Salbutamol 3x2 mg
IP Mx : vital sign
IP Ex:
Tell patient and his family about his illness
Reducing cold weather
Breathe exercise
3. Hiperglikemia
Ass : TGT
Ip Dx : TTGO
Ip Tx:
o Farmacology

o Non farmacology
-

DM diet

Normo BMI

exercise

Ip Mx : GDS , GDP (6 bulan sekali)

Ip Ex:
-

Explain about the disease

Maintain weight
Reduce smoking
Mild Exercise at least 30 minute in everyday
DM diet

4. Hiponatremia
Ass :
Ip Dx :
Ip Tx: Infus NaCl 0,9 %
Ip Mx : Vital sign, ECG, evaluasi kesadaran, koreksi elektrolit
Ip Ex: diet tinggi garam
J. Follow Up
Date
15-7-2015

Complains
Dyspneu, Chest pain

BP
130/100

HR
91x

RR
40x/mnt

T
36 C

16-7-2015

Chest pain

130/90

90x

20x/mnt

36 C