CBD

CASE BASE DISCUSSION

MUZNA MICI RUCHYANTI

30101307017
Advisor :
dr. H. M. SAUGI ABDUH, Sp.PD., KKV, FINASIM

Department of Internal Medicine

Medical School of Sultan Agung Islamic University
2016
 PATIENT’s IDENTITY
Name : Mr. M
Age : 58 years old
Gender : Male
Religion : Moslem
Job : Farmer
Address : Dusun Paras 01/04 Padang Tanggungharjo
Grobogan
MR number : 01331560
Room : Baitul Izzah 1 – 408.H2
Entry date : 20 October 2017
Date out : 26 October 2017
HISTORY TAKING
Abdominal pain

Patient came to ER of Sultan Agung Islamic Hospital with

complaint abdominal pain since 2 days ago. He felt the pain on
all of abdomnen, another complaint is nausea, vomiting and his
feces color is black. He also loss appetite, only can drank water,
already get medicine but did not felt better.
 HISTORY OF ILLNESS
HISTORY OF PREVIOUS ILLNESS SOSIO-ECONOMIC HISTORY :
Hypertension history (-) Hepar disease (-) Hospital cost certified by
Alkohol (-) Jamu (+)
JKN NON PBI
DM history (-) Gastritis (+)
Asthma history (-)
Alergy history (-)
Smoking (-)
Tranfution history (-)

FAMILY’S HISTORY OF DISEASE

Hypertension history (-)

DM history (-)

Asthma history (-)

Alergy history (-)

Hepar disease (-)

 SISTEMIC ANAMNESIS
Main Complains : Abdominal pain
Onset : 2 days ago
Location : Abdomen (all)
Quality and Quantity : Patient feel pain everytime, intermittent, and
disturbing activities,
Chronology : already 2 days ago suddenly felt pain on his abdomen, he felt
nausea and vomitting, if he ate some food, he would vomitted the food. His
feces color is black, and he was constipated since 2 days in hospital.
Modification factor : in activity or rest still feel pain (everytime)
Comorbid complains : nausea, vomiting, black feces, loss appetite
 PHYSICAL EXAMINATION
General : feel pain

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

Head : headache (-)

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

Ears : hearing loss (-), discharge (-/-)

Nose : nosebleed (-), discharge (-), nostril breath (-)

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

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

Neck : enlargement of the gland (-)

Chest : cough (-), sputum (-), blood (-)

Cardiac : chest pain (-), palpitations (-)

Digestive : abdominal pain (+), nausea (+), vomiting (+)

Extremity : oedem extremity (-)

 GENERAL STATUS
BMI (Body Mass Indeks)
Weight : 75 BMI =29.29
High : 160
Intepretation : Overweight

Awareness : Fully Aware / Compos Mentis

Vital Sign :
Blood Pressure : 120/80 mmHg
Heart rate : 85 x/minute
Breath Frequency: 22 x/minute
Temp : 36,5oC

Intepretation : Normal
 GENERAL STATUS
Head : Mesocephal, alopesia (-)

Eyes : Anemic conjuntiva(-/-), icteric sclera(-/-)

Nose : symmetric, secret (-), nostril breath (-)

Ears : Normal shape, discharge (-/-)

Esophagus : Hyperemic (-), swallow pain (-)

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 : 22x/min, Hyper pigment (-), spider nevi RR : 22x/min, hyper pigment
(-), atrophy pectoral muscle (-), hemithoraks D=S, (-), spider nevi (-), hemithoraks 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 retraction abdominothorakal breathing (-), muscle
of breathing (-), retraction of breathing(-),
retraction ICS (-) retraction ICS (-)

Palpation Palpable pain (-), tumor (-), enlargement of ICS (-), Palpable pain (-), tumor (-), Stem fremitus D=S
Strem fremitus D=S
Percution Dimmed in the lung bases Dimmed in the lung bases

Auskultation Vesicular (-), Whezzing (-), Ronchi (-) Vesicular (-), Whezzing (-), Ronchi (-)

Intepretation : normal
 CARDIAC EXAMINATION
Inspection : Ictus cordis isn’t 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 parasternal line
 Lower right borderline of heart : ICS V right sternal line
 Lower left borderline of heart : ICS VI mid clavicula
 ...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 (-), caput medusa (-)
Auscultation : peristaltic (-), bruit (-)
Palpation :
Superfisial : tight (+), mass (-)
Deep : abdominal pain (+), pain press (+), liver palpalable (-),
abdominal muscle spasm (-) , kidney, and spleen weren’t,
palpable, Murphy’s sign (-)
Percussion : tympani, shifting dullness (-)
Liver : deaf (+), right liver span 9 cm, left liver span 5 cm
Spleen :Throbe space percussion (+)  tympani

Intepretation : hepatomegali
EXTREMITIES EXAMINATION
Extremities Superior Inferior

• Oedema -/- -/-

• Cold -/- -/-

• Jaundice -/- -/-

LAB. EXAMINATION 12/8/2016
HEMATOLOGY nilai Nilai normal
Routine Blood 1
Hemoglobin 3.3 g/dl 13.2 – 17.3
Hematokrit 11.4 % 33 -45
Leukosit 25.02 thousand/uL 3.8 – 10.6
Trombosit 347 thousand/uL 150- 440
Blood Group / Rh O / Positif
IMUNOSEROLOGY
Kualitatif HBsAg Non Reaktif 0Non reakrif
CHEMISTRY
SGOT 163 U/I (H) 75 – 110
SGPT 44 U/I 0 - 50
Gula Darah Sewaktu 136 0 - 50
 nilai Nilai normal
Ureum 110 10 – 50 mg/dl
Creatinin 2.50 0.7 – 1.3 mg/dl
Natrium 133.2 135 – 147 mmol/L
Kalium 3.85 3.5 – 5 mmol /L
Chloride 107.7 96 – 105 mmol L
 USG
• Hepar ukuran membesar ringan, tepi regular, ekogenisitas parenkim
normal, tak tampak nodul, V. Porta dan V. Hepatika tak lebar
• Ductus biliaris intra dan ekstrahepatal tak lebar
• Vesica fellea dinding tak tebal, tak tampak batu
• Pancreas ukuran normal, parenkim ormal ductus pancreaticus tak
lebar
• Lien ukuran normal, parenkim normal, V. Lienalis tak lebar
• Paraaorta tak tampak kelainan
• Ginjal kanan ukuran kecil, batas kortikomeduler masih baik,
ekogenisitas parenkim meningkat, PCS tak lebar, tak tampak
batu/massa.
• Prostat ukuran normal, tak tampak kalsifikasi ataupun nodul
• Tak tampak cairan bebas intraabdomeinal
• Conclusion :
• Mild Hepatomegaly
• Size of renal sinistra is smaller than normal. It
suspected chronic kidney disease Tak tampak
batu atau bendungan pada traktus urinarius
• No sign of Porta Hipertension
• Splen, renal and pancreas is normal
 Abnormal Data

Lab
History Taking
Hematology
1. abdominal pain, Physical & additional
10. Anemia
2. nausea, Examination
11. Azotemia
3. vomiting, 6. Abdominal pain,,
12. Hiponatremia
4. black feces, 7. press pain,
13. Hipochloride
5. Loss appetite 8. Hepatomegali
ringan
 PROBLEM LIST

1 3 4
Abdominal Anemia Mild
pain (1) (2,3,5) Hepatomegali

2 6 7
Melena ( 4) Hiponatremia Obesitas

5
Azotemia
 Melena
• Ass :
- Gastritis erosif,
- Varises esophagus

• Ip Dx : Endoscopy.
• IP Tx :
Inj. Omeprazole 40 mg/vial,
Omeprazol tab 20mg
Sucralfate 2x1  mucoprotector
• Ip Mx : Vital Sign, melena.
• Ip Ex :
- Explain about his illness.
- Stop use herbal drug without advice the doctor
- Eat the smooth food
 Anemia
Ass :
Anemia normokrom normositer (Anemia penyakit
kronik, anemia aplastik, keganasan mieloma, AIHA)
Anemia hipokrom mikrositer (Anemia def.Fe,
Thalasemia, anemia penyakit kronis, anemia
sideroblastik, anemia pasca perdarahan akut)
IP Dx : hematology (MCV, MCHC, MCH), peripher blood,
Fe serum
Ip Tx :
Pharmacology :
PRC Transfussion (until Hb : 9-10)
Ip Mx: Vital sign, Hb level, transfusion reaction
Ip Ex : Bed rest, keep hygienity, eat medicinie regulary
 Acute abdominal Pain
• Ass :
- Peptic ulcer
- Pancreatitis
- Kolesistitis, kolelitiasis

• Ip Dx : Endoskopi, ERCP
• IP Tx :
Pharmacology :
Inj.Ketorolac 1 amp

• Ip Mx : Vital Sign and pain scale

• Ip Ex :
- Explain about his illness.
 Mild Hepatomegali
• Ass :
Etiologi :
- Hepatitis virus,

• Ip Dx
Virus Serology (Anti HAV, Anti HBV, HbsAg, HbeAg, Anti HCV (IgM &IgG), HCV RNA kualitatif, HCV RNA
kuantitatif)

• Ip Tx
Curcuma tab 3 x 1
Ursodeoxycholic acid 250 mg 3x1

• Ip Mx
Vital Sign, Fuction liver test (ALT)

• Ip Ex
- Explain his illness
- Decrease his weight with exercise and diet low fat
 Azotemia
• Ass : Insufisiensi Renal
• Ip Dx :
Glomerulus Filtration Rate
• Ip Tx :
Principal therapy : inhibit progressivity
Non Pharmacology :
- Limitation of protein intake (0.6-0.8/kgBB/day),
- Control w
Pharmacology :
• Ip Mx : vital sign, Ureum creatinin level
• Ip Ex
Intake low protein, emphasize such as fresh
vegetables, whole grains, nuts, legumes, low-fat or
nonfat dairy products, canola oil, olive oil, cold-
water fish, and poultry.
• be encouraged to take exercise (aiming for at
least 30 minutes 5 times per week), achieve a
healthy weight (BMI 20-25, according to country
specific demographics), and stop smoking.
 Glomerulus Filtration Rate
• Laju Filtrasi Glomerulus (LFG) :
140−𝑈𝑚𝑢𝑟 𝑥𝐵𝐵 (𝑘𝑔)
= 𝑚𝑔
72𝑥𝑠𝑒𝑟𝑢𝑚 𝑘𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛( )
𝑑𝐿
• Laju Filtrasi Glomerulus (LFG) :
140−58 𝑥75 (𝑘𝑔)
= 𝑚𝑔
72𝑥2.5 ( )
𝑑𝐿
6150
= = 34.1  Insufisiensi renal grade 3
180
 Glomerulus Filtration Rate
• Laju Filtrasi Glomerulus (LFG) :
140−𝑈𝑚𝑢𝑟 𝑥𝐵𝐵 (𝑘𝑔)
= 𝑚𝑔
72𝑥𝑠𝑒𝑟𝑢𝑚 𝑘𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛( )
𝑑𝐿
• Laju Filtrasi Glomerulus (LFG) :
140−58 𝑥70 (𝑘𝑔)
= 𝑚𝑔
72𝑥2.5 ( )
𝑑𝐿
5740
= = 31.8  Chronic Kidney Disease grade 3
180
 HIPONATREMIA
 Assesment
-
 IP. Dx
-
 IP. Tx
Natrium correction :
(140- 133.2) x (80 x 0.5)=
6.8 x 35 = 238 mEq/L
NaCl 0.9% 1.5 flabot ( 1 flabot NaCl 0,9 % : Na 154 meq/L ; Cl 154 meq/L )

IP. Mx
Natrium status post correction, General state, Awareness, Vital Sign
IP. Ex
Explain about disease
IP. Mx
Natrium status post correction, General state, Awareness, ECG, Vital Sign
IP. Ex
Exercise about 30 minutes /day
Follow rules of diet with calory calculation
 Overweight (Pre-Obese)
 Assesment
-
 IP. Dx
-
 IP. Tx
Non Pharmacology : Diet with calory calculation patients
use Harris Bennedict’s formula

Total kebutuhan energi

1462 kcal /day
 Rumus lain kebutuhan kalori
• Berat Badan Ideal:
(160 -100) - 10% = 54 kg
Kalori Basal:
54 x 30 kal = 1620 kal
Koreksi: Aktifitas berat
(+40% kalori BMI normal)
Koreksi Kalori Total :
• 1620 + 648 = 2268 kalori
THANKYOU