Department of Internal Medicine

Faculty of Medicine Sultan Agung Islamic University

2017

Case Based Discusion

Endika Cahyo Kuncoro / Yossi Reza Gimawan
012095895 / 012106298
Advisor :
dr. H. M. SAUGI ABDUH, Sp.PD., KKV, FINASIM
Patient Identity

Name : Mrs.SW
Age : 60 y.o.
Gender : Female
Religion : Moslem
Job : Housewife
Address : Ngablak kidul, 8/8, pedurungan Semarang
MR number : 01026680
Room : Baitul Izzah 2
Entry date : july 4rd, 2017
Date out : july 5th, 2017
History taking

Main Problem
Epgastric pain

History of present illness

Patient come as outpatient to the clinic on Sultan Agung
Islamic hospital with Epgastric pain that does not heal
after 3 days. Her Epgastric pain does not heal after she
takes some medication that she usually took. Patient also
came with nausea,vomitus and decreased body weight.
HISTORY OF ILLNESS
HISTORY OF PREVIOUS ILLNESS
SOSIO-ECONOMIC HISTORY :
Hypertension history (+)
Hospital cost certified by
DM history (+)
BPJS N-PBI
Asthma history (-)
Alergy history (-)
SMOKING (-)
Uric Acid (-)
FAMILYS HISTORY OF DISEASE

Hypertension history (+)

DM history (+)

Asthma history (-)

SISTEMIC ANAMNESIS
Chief Complains : epigastric pain

Onset : 3 day ago

Location : Abdomen

Chronology : Patient was having epigastric pain on 3 day ago, have

an nausea and vomitting once

Quality and Quantity : His epigastric was coming everyday and

everytime without spesific condition

Modification factor : Better when she took a rest

Comorbid complains : nausea, vomitting, weight loss

 PHYSICAL EXAMINATION
General : composmentis Throat : pain swallow(-), hoarseness (-),
Skin : itching (-), jaundice (-), pale (-) odinifagia (-)
Neck : enlargement of the gland (-)
Head : headache (-)
Chest : cough (-), sputum (-), blood (-)
Eyes : blurred vision (-), red eyes (-),
Cardiac : chest pain (-), palpitations (-)
icteric sclera (-/-)
Digestive : abdominal pain (+), nausea (+),
Ears : hearing loss (-), ring (-), vomiting (-)
discharge (-) Musculoskeletal : weak (-), rigid (-), back pain (-)

Nose : nosebleed (-), discharge (-) Extremity : oedem extremity (-)

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

bleeding gums (-)
GENERAL STATUS
BMI (Body Mass Indeks)
weight : 40 BMI= 40/(1.5 x1.5) = 17,78
High : 150
Intepretation :
underweight

General : weakness
Awareness : Fully Aware / Compos Mentis (GCS=15)
Vital Sign
Blood Pressure : 120/90 mmHg
Heart rate : 86 x/minute
Breath Frequency : 20 x/minute
Temp : 36,0oC
Intepretation :
normotension
GENERAL STATUS
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 (-)

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

Intepretation : Normal
LUNG EXAMINATION
INSPEKSI ANTERIOR POSTERIOR

Static RR : 20x/min, Hyper pigment (-), spider nevi RR : 20x/min, Hyper pigment
(-), atrophy Pectoral Muscle (-), Hemithoraks (-),spider nevi (-), Hemithoraks D=S,
D=S, ICS Normal, Diameter AP < LL ICS Normal, Diameter AP < LL

Dynamic Up and down of hemitoraks D=S, Up and down of hemitoraks D=S,

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

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

Percution Sonor Sonor

Auskultation Vesicular (+), Whezzing (-), Ronchi (-) Vesicular (+), Whezzing (-), Intepretation :
Ronchi (-) 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 V, 2 cm lateral from left
mid clavicle line
 ...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 : NORMAL
ABDOMEN EXAMINATION
Inspection : symetric, sycatric(-), striae(-),enlargement of vena (-),
caputmedusa (-).
Auscultation : peristaltic (+)
Palpation :
Superfisial : tight (-), mass (-), epigastrial pain (+)
Deep : abdominal pain (-), liver, kidney, and spleen werent
palpable, Murphys sign (-)
Percussion : tympani, side of deaf (-), shifting dullness (-)
Liver : deaf(+), right liver span 11 cm, left liver span 6 cm
Spleen : Throbe space percussion (+) tympani

Intepretation :
Abdominal pain
EXTREMITY EXAMINATION
Ekstremitas Superior Inferior

Oedema -/- -/-

Cold -/- -/-

Jaundice -/- -/-

Laboratorium Examination
 05/03/2017 Normal values
Troponin I Ultra 7.21 (H) < 0.01 ug/L

Ureum 130 (H) 10-50 mg/dL

Blood Creatinin 6.36 (H) 0.6-1.1 mg/dL

13.2-17.3 g/dL
Haemoglobin 9.0 g/dL (L)

Hematocrit 27.2% (L) 33-45 %

Leukosit 11.07 ribu/dL(H) 3.8-10.8 ribu/dL

Trombosit 310 ribu/dL (L) 150-440 ribu/dL

HbA1c 7.25 (H) <=5.4

Natrium 131.1 (L) 135-147 mmol/L

Kalium 4.25 3.5-5 mmol/L

Chloride 109.8 (H) 95-105mmol/L

Magnesium - 1.6-2.4 mmol/L

Calcium 10.0 8.8-10.8 mmol/L

Gds 477 75-100

Interpretation

Troponin I Ultra
Ureum
Creatinin
Haemoglobin (Anemia)
Hematocrytes
Leukosit
HbA1c
Chloride
Natrium
Glucose
ECG
 ECG Interpretation
Irama : Sinus Rhytm
Regularity : Regular
Frequency : 1500/23
65x/minute
Axis : LI :+
aVF : + Normo axis deviation
Transition zone : V3-V4
P : normal, less than 2 small box
PR : elongated in V3,V4,V5
6 small box ( 6x0,04 =0,24 s)
QRS complex : normal, 2 small box ( 0,08 s)
ST Segment : Elevation at II, III, aVL
T : theres no T inverted or T tall
Interpretation : av-block grade I
Ischemic anterior
 Abnormal Data ECG :
5.Inferior ischemic
6. Grade I AV-block

Lab
History Taking 7. Troponin I Ultra
Physical 8. Ureum (Azotemia)
1. Epigastric pain,
Examination 9. Creatinin
2.Nausea 3. vomitting 10. Haemoglobin (Anemia)
5.Epigastric pain 11. Hematocrytes
4. Weight loss
12. Leukocyte
13. HbA1c
14. Chloride
15. Natrium
16. Glukose
Problem List

1 CKD
(2,3,4,8,9,10,11,
12,14) 3 Anemia
(10,11,12,13)

2
4
Diabetes
melitus
(4,13,16) SKA
(1,5,6,7)
 Assassement : emergency condition to prevent
CKD metabolic acidosis, seizure, hyperkalemia, bleeding,
crisis hypertention, over hidration, infection.
IP Dx : BGA
IP Tx :
Non pharmacologic :
Limitation of protein intake (0.6-0.8/kgBB/day),
Calorie Intake 30-35 kkal/kgBB/day
Dialysis
Pharmacologic :
CaCO3 3x1

IP Mx
Vital Sign, GFRLFG, uremic sign, general state, awareness,
fluid balance
 IP Ex
Explain to the patient about the disease
Explain about dialysis
Take medicine regularly
Explain side effect of medication
Explain about proper daily intake, including type of diet and food
Routine Control of Blood Pressure
Chronic Kidney
Disease Grade V
 Kriteria CKD (terjadi lebih dari 3 bulan)
Penanda kerusakan ginjal (1 - Albuminuria (AER 30mg/24
atau lebih) jam; ACR 30mg/g (3
mg/mmol)
- Abnormalitas sedimen urin
- Abnormalitas elektrolit atau
lainnya yang berkaitan
dengan gangguan tubulus
- Abnormalitas struktur yang
dideteksi dari radiologi
- Riwayat transplantasi ginjal
Penurunan laju filtrasi GFR < 60 ml/menit/1,73 m2
glomerulus (GFR)
 Old Classification of CKD as Defined by Kidney Disease
26 Outcomes Quality Initiative (KDOQI) Modified and Endorsed
by KDIGO
Stage Description Classification Classification
by Severity by Treatment
1 Kidney damage with GFR 90
normal or increased GFR
2 Kidney damage with GFR of 60-89 T if kidney
mild decrease in GFR transplant

3 Moderate decrease in GFR GFR of 30-59 recipient

4 Severe decrease in GFR GFR of 15-29 D if dialysis

5 Kidney failure GFR < 15 D if dialysis

Note: GFR is given in mL/min/1.732 m

KDIGO, Kidney
National Kidney Foundation. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Disease: Increasing
Evaluation, Classification, and Stratification. Am J Kidney Dis 2002;39(suppl 1):S1-S266 Global Outcomes
Rencana Tatalaksana Penyakit Ginjal Kronik sesuai
dengan derajatnya (Sudoyo, 2014)

Derajat LFG (mlmnt/1.73 m2) Rencana tatalaksana

1 90 Terapi penyakit dasar, kondisi komorbid,
evaluasi perburukan (progression) fungsi
ginjal, memperkecil risiko kardiovaskuler

2 60-89 Menghambat perburukan (progression)

fungsi ginjal

3 30-59 Evaluasi dan terapi komplikasi

4 15-29 Persiapan untuk terapi pengganti ginjal
5 <15 Terapi pengganti ginjal
 Kidney Disease: Improving Global Outcomes
(KDIGO) CKD Work Group. Kidney Int Suppls.
2013;3:1-150.
 Indikasi hemodialisa
Hemodialisis segera atau
emergency
Uremia ( BUN >150mg/dL)
Oliguria (urin < 200ml/12jam)
Anuria (urin < 50ml/ 12jam)
Asidosis berat (pH < 7.1)
Hiperkalemia
Ensefalopati uremikum
Neuropati Uremikum
Hipertermia
Disnatremia (Natrium > 160
atau < 115 mmol/L)
Hemodialisis kronik, yaitu
hemodialisis yang dilakukan
seumur hidup
Dimulai apabila dijumpai
salah satu gejala yaitu :
a. LFG < 15ml/menit,
tergantung gejala klinis
penderita
b. Malnutrisi atau hilangnya
massa otot
c. Gejala uremia antara lain
anoreksia, mual muntah,
lethargy
d. Hipertensi yang susah
dikontrol
e. Kelebihan cairan
 KOMPLIKASI
32
Diabetes
Melitus Assassement
Acute :
Hiperglikemia KAD
Hipoglikemia
Chronic :
Makroangiopathy : CHD, Cerebrovascular dissease,
Mikroangiopathy : Retinopathy Diabetic, Nefropathy diabetic
IP Dx : plasma glucose and HbA1c serum
 IP Tx :
Humalog 3x16unit
Glikuidone 1-0-1
IP Mx :
Vital Sign, plasma glucose
IP Ex
Manage diet
Explain to increase exercise
explain to take a medication regulary
 Ass: Ischemic Inferior,
SKA AV-Block grade I
Pharmacology
O2 nasal canul 4L/minute
IP Dx : Angiografi koroner
ISDN subl. 5 mg 3x1
IP Tx : prn
Non Pharmacology Aspillet 80 mg 1x1
Low cholesterol intake CPG 75 mg 1x1
Reduce activity Heparin
High fiber diet
O2 nasal canul
4L/minute
Low Fat Intake
 Ip. Mx : Vital sign, ECG serial, echocardiography, APTT

Ip. EX :

Bed Rest/Restriction of physical activity

Reduce fatty food

Reducing Emotional stress

Routine consumption drugs

Consumption of antioksidan (green tea)

Do sport regularly, 4 times each week, duration: 30-60 minutes

Anemia Assassemen : anemia mikrocytic hipochromic, anemia
normositic normochromic, anemia makrositic
IP Dx : eritrocyte morphology examination (MCV, MCH,
MCHC), complete blood count
IP Tx :
Non pharmacological : PRC tranfsusion 2 colf
Pharmacological : Folic Acid 1x1, EPO preparat
IP MX
General state, Awareness, Vital Sign, Routine blood (Hb, Ht)
IP Ex
Explain about Anemia
Explain about treatment of anemia
Explain about side effect of anemias treatment