Case Based Discussion

Diajukan untuk
Memenuhi tugas kepaniteraan klinik dan melengkapi salah satu syarat
menempuh Program Pendidikan Profesi Dokter di Bagian Ilmu Penyakit Dalam
RSI Sultan Agung Semarang

Disusun oleh:
Ayu Rizqi Nurul Iriani
012085617

Pembimbing:
dr. Hj. Nur Anna C. Sadyah, Sp.PD

BAGIAN ILMU PENYAKIT DALAM

FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM SULTAN AGUNG
SEMARANG
2013
 Patients identity
Name : Mrs. Ng
Age : 45 years old
Sex : Female
Religion : Moslem
Adress : Condrorejo 04/11 Pedurungan Semarang
No. CM : 108 39 54
Ward : Baitul Izzah 1 (411.5)
Status : Social health insurence
Date in : 22.1.2013
Date out : 28.1.2013

Main problem
Dypsneu

History of present illness

Patient came to the hospital present with chief complains is dyspneu continuely. Her
complains felt since a week ago. So that she had to take a rest all day and no
improvement. In addition, the patient also complained loss of appetite accompanied by
headache and weakness. During complain, the patient has never been treated, and see a
doctor.

History of past illness

H. Similiar complaint : recognized
H. Hypertension : denied
H. DM : recognized
H. Maag : denied
H. Asthma : denied
H. Drug allergy : denied
H. Tbc : recognized since 2008
 Familys illness history
No similiar family complains

Socio-economic history
Medical expenses social health insurence
Suggest less economic

Sistematic anamnesis
Skin : itch (-) wound (-) jaundice (-) pale (-)
Head : headache (+)
Eyes : red eye (-/-) anemic conjungtiva (-/-) icteric sklera (-/-)
Ears : hearing lose (-/-) ringing (-/-) discharge (-/-)
Nose : epistaxis (-/-) discharge (-/-)
Mouth : sianosis (-) sprue (-) bleeding gums (-)
Throat : sore throat (-) husky (-) hiperemis (-)
Neck : swelling (-) stiff (-)
Chest : dyspneu (+) chest pain (-) palpitation (-)
Gastrointestinal: lost appetite (+) nausea (-) vomitus (-) bloating (-) hematemesis (-) micti
(+) defecation (+) abdominal pain (-)
Urogenital: tea colour of urination (-) pain urination (-)
Muskuloskeletal: paresthesia (-) low back pain (-)
Nerve : dizzines (-)
Extremity: sup: edema (-/-) sianosis (-) inf: edema (-/-) sianosis (-)

Physical examination
Vital sign
BP = 130/80 mmHg
HR = 100 x/menit
RR = 26 x/menit
T = 36,5 oC

BMI
BB = 40 Kg
TB = 150 cm

Impression :
Dyspnue
BMI 17,7 (underweight)

Calorie requirement
Sex = BB ideal (Brocca) x 25 calorie/KgBB
= 45 Kg x 25 calories
= 1125 calories (basal calorie)
Age = 46 years old (-10% x 1125)
= - 112,5 calories
Temperature =0
Activity = +10% x 1125 calories
= +112,5 calories
BMI underweight = +20% x 1125 calories
= +225 calories

From above, we can accumulate

= basal calorie + age + temperature + activity + BMI underweight
= 1125 + (-112,5 ) + 0 + 112,5 + 225
= 1350 calories round to 1400 calories

So, Mrs. Ng need1400 calorie/day, then divided to 3x great meals and 2x snacks:
Breakfast 7.00 a.m. = 400 calories
Snack (1) 10.00 a.m. = 75 calories
Lunch 1.00 p.m. = 550 calories
 Snack (2) 4.00 p.m. = 75 calories
Dinner 7.00 p.m. = 300 calories
Head : mesocephal (+) alopecia (-)
Eyes : red eye (-) anemic conjungtiva (-/-) icteric sclera (-/-)
Nose : symmetric, discharge (-) nostril breath (-)
Ears : normal shape, discharge (-)
Esophagus : hyperemic (-) sore throat (-)
Mouth : cyanosis (-) dry lips (-)
Neck : trachea deviation (-) lymph gland swelling (-)
Impression : normal

Thorax - pulmo

INSPEKSI ANTERIOR POSTERIOR

STATIC RR: 26 x/min, hyperpigmentation (-), RR:26 x/min, hiperpigmentasi (-),

tumor (-), inflammation (-), spider nevi tumor (-), inflammation (-), spider
(-), hemithorax D = S, ICS Normal, nevi (-), hemithorax D = S, ICS
Diameter AP < LL Normal, Diameter AP < LL

DINAMYC The movement of hemitorax D = S, The movement of hemitorax D =

abdominothorakal breathing (-), muscle S, abdominothorakal breathing (-),
retraction of breathing (-), retraction muscle retraction of breathing (-),
ICS (-) retraction ICS (-)

PALPATION Palpation pain (-), tumor (-), arcus Palpation pain (-), tumor (-),
costae angle < 900, enlargement of ICS enlargement of ICS (-), sterm
(-), stem fremitus D = S fremitus D = S
PERCUTION Hipersonor in the right lungs Hipersonor in the right lungs
AUSCULTATION ronchi (+) wheezing (-) vesikuler (+) ronchi (+) wheezing (-) vesikuler (+)

IMPRESSION Dyspnue

Thorax - cor

INSPECTION
 Ictus cordis cant be seen
PALPATION
Ictus cordis is palpable at ICS V, 2 cm medial from linea mid clavicula sinistra, thrill (-),
pulsus epigastrium (-), pulsus parasternal (-), sternal lift (-)
PERCUTION

Dull sound
: ICS II linea sternalis sinistra
Upper borderline
: ICS III linea parasternalis sinistra
Waist
: ICS V linea sternalis dextra
Lower right borderline
: ICS V, 2 cm medial from linea mid clavicula
Lower left borderline
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
IMPRESSION : NORMAL

Abdomen

INSPEKSI
Symetric, sycatric (-), striae (-), scuama (-) enlargement of vena (-), hyperpigmentasi (-),
spider nevi (-)
AUSKULTATION
peristaltic (+) Normal (20 x/minutes)
PERCUTION
Hepar : deaf (+), liver span dextra 9 cm, liver span
side of deaf (-), shifting
sinistra 5 cm
dullness (-), undulation
Lien : traube space perkusi dull sound
(-)

PALPASION
Superfisial : Deeper:
massa (-) abdominal abdominal pain (-)
pain (-) hepar is not palpable, lien is not palpable, kidney is
 not palpable.

IMPRESSION NORMAL

Extremity
Ekstremity Superior Inferior

Oedem -/- -/-

Cold akral -/- -/-

Fisiologis reflect +/+ +/+

Ikteric -/- -/-

Impression NORMAL

ECG
 Rhythm : reguler
Frequency :1500 : 13 = 115 x/menit
Axis : LAD
Transition zone :-
P wave : 0,12 sec
PR Interval : 0,2 sec
QRS complex : 0,8 sec
ST Segment : elevation in v2, v3, v4, v5, v6
T wave : 0,16 sec
Impression : infark miokard

2013, 13th February

Examination Result Unit Normal value
Hematology
Hemoglobin 12,7 g/dl 11,7-15,5
Hematocrit 39,7 % 33-45
Leukocyte 11,1 Thousand/uL 3,6-11,0
Platelet 577 Thousand/uL 150-440
Blood group/ Rh O/ positive
Chemical
GDS 387 mg/dl 75-110
Immunoserology
Qualitative HBsAg Negative Negative

2013, 15th February

Examination Result Unit Normal value
Urine
Color Yellow
Clarity Cloudy
Protein Negative mg/dl <30 mg/dl (-)
Reduction 100 mg/dl <15 mg/dl (-)
Bilirubin Negative mg/dl 1 mg/dl (-)
Reaction/ pH 5,0 4.8-7.4
Urobilinogen 0,2 mg/dl <2 mg/dl
Ketone bodies Negative mg/dl <15 mg/dl (-)
Nitrite Positive Negative
Dencity 1.025 1.015-1.025
Blood Negative Eri/uL <5 Eri/uL
 Leukocyte 70 Eri/uL <10 Eri/uL
Examination Result Unit Normal value
Microscopic
Epitel cell 3-5 5-15/ LPK
Erytrocite 0-2 0-1/ LPB
Leucocyte 72-74 3-5/ LPB
Silinder Negative Negative
Parasit Negative Negative
Bacteria +2 Negative
Fungi Negative Negative
Crystal Negative Negative
Mucous yarn Negative Negative

2013, 23th January

Lungs Tb,
with cavitation in the right lung field,
not visible improvements

2013, 23th January

Examination Result Unit Normal value
Microbiology
BTA (sputum) S 1 = 3+ Negative

2013, 24th January

BTA (sputum) P = 2+
BTA (sputum) S 2 = 3+

2013, 25th January

Chemical
Ureum 32 mg/dl
Blood creatinin 0,5 mg/dl
 SGOT 18 U/I 0-35
SGPT 29 U/I 0-35

Abnormalitas data
History taking
1. Dyspnue
2. Weakness
3. Loss of appetite
4. Headache
5. DM (+)
6. Tbc (+)
Physical examination
7. Dyspnue
8. BMI underweight
9. Pulmo percusion hypersonor
10. Pulmo auscultasion ronkhi (+)

Laboratory result
11. ECG
12. X-Ray lungs TB
13. Hematology
a. Leukocyte 11,1
b. Platelet 577
c. GDS 387
14. Urine
a. Reduction 100
b. Nitrite +
c. Leukocyte 70
15. Microscopic
a. Epitel cell 3-5
b. Eritrocyte 0-2
 c. Leukocyte 72-74
d. Bacteria +2
16. Sputum BTA
S1 3+
P 2+
S2 3+

Problem list
Lungs TB (1, 2, 3, 4, 5, 6, 7, 9, 11)
DM Type 2

Problem investigating
Lungs TB (1, 2, 3, 6, 7, 8, 9, 10, 12, 13a)
DM Type 2 (2, 5, 8, 13c, 14)

Treatment Planning for Lungs TB

Supporting diagnostic plan

Sputum BTA SPS, X-Ray
Treatment planning
Non pharmacologi : bed rest, nutient
Pharmacology :
R/ Ciprofloxacin S 2ddI
R/ Spironolacton S 1--0
R/ Salbutamol S 3dd
R/ DOTS kategori II S 1ddIII
R/ Streptomicyn 750 mg S imm
Education planning
 Open the window for getting sirculation and sunshine to reduce humidity, nutient , bed
rest, regularly medication, dont spit carelessly, closes mouth by hand when coug or
sneezing

Treatment Palnning for DM Type 2

Supporting diagnostic plan

Routine blood, GDS, routine urine
Treatment planning
Non pharmacologi : Bed rest, diet sugar and cholesterol , routine exercise
Pharmacology : Humulin R 3 x 15 unit
Education planning
Consumpting sugar and cholesterol , routine exercise DM foot, regurlarly control GDS
and medication, good stress management

Prognostic
Ad vitam : ad bonam if eat and medication regularly
Ad sanationam : ad malam
Ad functionam : ad malam

Follow Up

Date BP HR RR T S O A P
22.1.2013 130 100 26x 36,5 Dyspneu, Composmentis, Tbc, Sputum BTA S1,
80 oC headache, weakness, DM ECG, routine
weakness, GDS 387 Type 2 blood lab, X-
cough Ray, diet sugar

23.1.2013 110 116 20x 37,6 Headache, Composmentis, Tbc, Sputum BTA P
70 oC cough weakness DM and S2, diet
Type 2 sugar , GDS
24.1.2013 90 100 20x 38 Headache, Composmentis, Tbc, Eat regularly,
60 oC cough weakness DM diet sugar ,
Type 2 GDS
25.1.2013 100 60x 20x 36 Weakness, Composmentis, Tbc, Eat regularly,
80 oC sprue weakness DM diet sugar ,
Type 2 GDS

26.1.2013 100 80x 20x 36,4 Headache, Composmentis, Tbc, Eat regularly,
60 oC cough weakness DM diet sugar ,
Type 2 GDS

27.1.2013 90 105 22x 36,9 Headache, Composmentis, Tbc, Eat regularly,

60 oC cough better DM diet sugar ,
Type 2 GDS
28.1.2013 90 100 22x 36,4 Cough Composmentis, Tbc, Eat regularly,
50 oC better DM diet sugar ,
Type 2 GDS