CASE BASED DISCUSSION

Diajukan Untuk Memenuhi Tugas Kepaniteraan Klinik dan Melengkapi Salah

Satu Syarat Menempuh Program Pendidikan Profesi Dokter
Bagian Ilmu Penyakit Dalam
Rumah Sakit Islam Sultan Agung Semarang

Disusun oleh:
Agata Nudiayona
30101306855

Pembimbing:

dr. Lusito, Sp.PD

BAGIAN ILMU PENYAKIT DALAM

FAKULTAS KEDOKTERAN UNIVERSITAS ISLAM SULTAN AGUNG
SEMARANG
2018
 CASE REPORT

A. Patient Identity
 Name : Mr. A.S
 Age : 31 years old
 Gender : Male
 Religion : Islam
 Job : Porter
 Number of Medical record : 012xxxx
 Address : Jalan Kaligawe Raya
a. room : Baitul Izzah 1 H4
b. status care : NPBI

B. Data
1. Anamnesis
 Main Problem : Dispneu
 History Taking
Patient came into Emergency Room in Islamic Hospital of
Sultan Agung at 16.00 pm. Complained that he had dispneu since 1
week ago. The dispneu felt as difficult to breath. It worst in the
night after he worked in the night and it is better when he took a
rest. He never consume the medicine, he always ignore his ill.
Another complaines he told aret light cough, headache, stomache in
the lift side, fatigue, imes with watery concentration. He also
complained nausea and vomitus of food and water, bitter mouth,
fever ( rise in the night, down in the noon, increase everyday),
difficult to swell.

 History of Previous Disease

 History of Previous Disease
 DM History :-
 Hipertention History :+
 Gastritis Hisory :+
  DHF Hisory :-
 Thypoid History :+
 Stroke Hisory :-
 Heart Disease Hisory :-
 Allergy :+
 Smoking :-
 Asma :+
 Ani Fistule :+
 History of Family Disease :-
 DM History :-
 Hipertention History :+
 Asma :+
 History of social-economy
BPJS NPBI

C. Systematic Anamnesis
 Main Complain : Dispneu
 Onset : 7 days
 Quantity : Everyday
 Quality : Difficult to breath
 Modification factor : Cold Situation
 Another Complain : Nausea, Vomitus, light cough, headache,
stomache in the lift side, fatigue, bitter mouth, fever ( rise in the night,
down in the noon, increase everyday), difficult to swell.

D. Physical Examination
General Status : fatigue
Awareness : compos mentis

Vital Sign
 Blood Pressure : 164/103 mmHg
 Heart Rate : 92 x/menit
 Respiration Rate : 30 x/minute
 Suhu : 37,59 o C
Nutritional Status
◦ Antropometric status
 Height = 158 cm and Weight = 85 kg
BMI = BB(kg)/TB²(m²) = 85kg/(1,58m)²
= 35,05 (overweight I)
General Status
 General : Fatigue
 Skin : gatal (-), pucat (-). Petekia (-) turgor <2 second
 Head : Headache (-), Dizzines (+)
 Eye : blurred vision (-/-), anemic conjungtiva (+/+),
sclera ikterus (-/-)
 Ear : Hearing disorder (-/-), discharge (-/-)
 Nose : simetris, nostril breath (-), epistaksis (-), discharge (-)
 Mouth : sianosis (-), tounge deviation (-), stomatitis (-).
 Throat : Hiperemis (-)
 Neck : trachea deviation (-), Tyroid hipertropy (-)
lymph hipertropy (-)
Thorax
Pulmo:
INSPECTION ANTERIOR POSTERIOR

Static RR :30 x/min, Hiperpigmentasi RR : 30 x/min, Hiperpigmentasi (-),

(-), Hemithoraks D=S, ICS Hemithoraks D=S, ICS Normal,
Normal, Diameter AP < LL Diameter AP < LL
.

Dynamic Dyspneu, Up and down of Dyspneu, Up and down of hemitoraks

hemitoraks D=S, D=S, abdominothorakal breathing (-),
abdominothorakal breathing, (-), muscle retraction of breathing(-),
muscle retraction of breathing (-), retraction ICS (-)
retraction ICS (-)

PALPATION Palpable pain(-), tumor (-), Arcus Palpable pain(-), tumor (-), Arcus
costae angle < 900, enlargement of costae angle < 900, enlargement of ICS
 ICS (-), Stem fremitus decrease (-), Stem fremitus decrease (-)
(-)

PERCUSSION Sonor Sonor

AUSKULTATIO Vesicular (-), Whezzing (+), Vesicular (-), Whezzing (+), Ronchi (-)
N Ronchi (-)

Cor :
INSPECTION
Ictus cordis isn’t seen

PALPATION
Ictus cordis is palpate at SIC VI 1 cm lateral linea mid clavicula sinistra
thrill (-) pulsus epigastrium (-), pulsus para-sternal (-), sternal lift (-)

PERCUSSION
- Upper borderline of heart : SIC II linea sternalis sinistra
- Waist of heart : SIC III linea para sternalis sinistra
- Lower right borderline of heart : SIC V linea sternalis dextra
- Lower left borderline of heart : ICS VI, 2 cm medial from left
midclavicle line
AUSKULTATION
 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 (-)

Abdomen
INSPECTION

symetric, sycatric (-), striae (-), enlargement of vena (-), caput medusa (-)

AUSCULTATION
peristaltic 20x/minute(+)

PERCUSSION

tympani, side of deaf (-), • Liver :deaf (+), right liver span 11 cm, left liver
shifting dullness (-) span 6 cm
: deaf (+), right liver span 11 cm, left liver span 6
cm

• Spleen: Throbe space percussion à tympani

PALPATION

Superfisial: Deep:
à tight (-), mass (-), à abdominal pain (-), liver, kidney, and spleen
epigastrial pain (-) weren’t palpable, Murphy’s sign (-)

Extremity

EXTREMITY Superior Inferior

Oedem -/- -/-
Cold Extremity -/- -/-
Physiological reflex +/+ +/+

Pathological reflex -/- -/-

Sensibillity +/+ +/+

Advance examination
1. HEMATOLOGI
Pemeriksaan laboratrium Hasil Nilai Normal
31-07-2018
Hemoglobin 13,2 - 17,3 g/dl
16,3 g/dl
Hematocrit 33 – 45 %
45 %
Leucocyte 3.8 – 11 ribu u/L
8,87 ribu/uL
Trombocyte 150 – 440 ribu/uL
267 ribu/Ul

2. IMUNOSEROLOGI
Sel Paratyphi B O Positif, 1/ 160

Sel Paratyphi C O Positif, 1/320

Sel Paratyphi B H Positif, 1/320

E. Abnormality Data
ANAMNESIS
1. Dypneu
2. Fatigue
3. Epigastris pain
4. Nausea
5. Fever
6. Difficult swell
7. Bitter
8. Dizziness
9. Gastritis History
10. Typhoid History
11. Hipertensi History
12. Alergy History
13. Eat willing decrease

PHYSICAL EXAMINATION
1. Konjungtiva Anemis
2. Sesak
3. Hipertensi grd II
4. Demam
5. Nyeri tekan abdomen
6. Nyeri epigstrik

PEMERIKSAAN PENUNJANG
1. EKG à sinus takikardi dengan iskemik inferior

F. Problem List
- Asma
 - Febris Observation
- Epigastric Pain
- Hypertension Grade III
- Obesity Grade III

G. Pembahasan Problem List

1. ASMA
Subject : sesak nafas
Object : (RR à 30 x/menit ; PF à wheezing +/+)

Assessment :
Faktor Predisposisi :
1. Alergi (suhu dingin)
2. Alergen (memelihara burung)
3. Aktivitas fisik berlebih
4. BMI : obesitas grade I

Ip Dx
• Foto Thorax Paru AP
• Uji Provokasi Bronkus
• Prick and patch Test
• Exhaled Nitric Oxide
• Darah rutin
• Apusan darah tepi à melihat jenis eusinofil (eusinofil meningkat)

Ip Tx
• NRM O2 10 lpm
• Nebulisasi B2 Agonis 1-2x, selang 20 menit (nebulà salbutamol
20 mg/2ml)
• Nebulisasi ke-2 + antikolinergik jika sesak sedang/berat
(prednisolon (antihistamin) 1mg/kgbb, max 50 mg)
• Nebul langsung dengan B2 Agonis + Antikolinergik

Ip Mx
• Vital sign
• SpO2
Ip Ex
• Kurangi BB
• Hindari Alergen
• Breathy Exercise Program

2. FEBRIS OBSERVATION
Subject : Badan panas
 Object : T à 39 oC
Assessment :
DD à demam typhoid, demam dengue, bronkopneumonia

Ip Dx
 Serologi IgM, IgG Salmonella Typhii
 Serologi IgM Anti Dengue
 Darah rutin
 Kultur Salmonella Thyphii (Gall Kultur)
 Foto Thorax

Ip Tx
• RL 20 tpm
• Paracetamol inj. 500 mg/250 ml 30 menit
• Cloramphenicol tab. 500 mg
• Ciprofloxacin 500 mg 2 x 1

Ip Mx
• Vital sign
• Hb Serial

Ip Ex
• Konsumsi air yang cukup
• Istirahat cukup (Bed Rest)
• Jangan makan di sembarang tempat
• Pakai kelambu di rumah
• Tanda dehidrasi

3. NYERI ULU HATI

Subject : nyeri ulu hati, mulut pahit
Object : palpasi à nyeri tekan ulu hati
Assessment : DD à gastritis, dispepsia, pankreatitis, ulcus duodenum, ulcus
gaster, GERD

Ip Dx
• Urea breath test
• Endoscopy
• Amilase lipase

Ip Tx
• Omeprazole 2x 20 mg
• Sucralfate Syr 100 ml (3 x 1 cth)
• Domperidone 2 x 10 mg

Ip Mx
• Keadaan umum
• Tanda dehidrasi

Ip Ex
• Menjelaskan penyakitnya
• Menjelaskan tentang jenis makanan yang dapat di konsumsi.

4. GRADE III HYPERTENSI

Subject : Pusing, Pegel-pegel
Object : TD : 164/103
Assessment : DD à Hipertensi Benigna dan Hipertensi Maligna

Ip Dx
• Funduscopy

Ip Tx
• CCB/ Thiazid
*CCB : Amlodipin : 5-10 mg, Diltiazem ER 180-360 mg
• ARB : Irbesartan (risiko kecil)

Ip Mx
• TTV

Ip Ex
• Kurangi makanan gorengan/ yang bergaram tinggi
• Olahraga
• Rutin minum obat à supaya terkontrol

5. GRADE III OBESITY

Subject :
Object : BMI à 34,05
Assessment : Komplikasi à SKA, Fatty liver, dislipidemia

Ip Dx
• Kolesterol
• Trigliserid
• HDL
• LDL

Ip Mx
• BB
• Cek Kolesterol

Ip Ex
• Kurangi makanan gorengan
• Olahraga (exercise)
 6. CHEST PAIN
Subject : Nyeri dada
Object : -
Assessment : UAP, N-STEMI

Ip Dx
• Echocardiography
• CKMB
• Troponin

Ip Tx
• ISDN (subl. 2 x 20-80 mg)
• Antiplatelet : 150-300 mg

Ip Mx
• TTV
• SpO2

Ip Ex
• Hindari aktivitas berlebih