CASE BASED DISCUSSION

Diajukan untuk

Memenuhi Tugas Kepaniteraan Klinik dan Melengkapi Salah Satu Syarat Menempuh

Program Pendidikan Profesi Dokter Bagian Ilmu Penyakit Dalam

Di Rumah Sakit Islam Sultan Agung Semarang

Disusun oleh:
Ardanti Putri
01.210.6084

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. BH
Age : 58 y.o.
Gender : Male
Religion : Moslem
Job : Unemployed
Address : Sriwulan RT 5/I Sayung, Demak
MR number : 108.14.05
Room : Baitul Izzah 2
Entry date : December 16th, 2015
Date out : January 30, 2016

B. Data
1. Anamnesis
Main problem: dyspneu

History patient illness :

Patient came to department penyakit dalam RSISA after received a referral from RS
Kraton Pekalongan with pneumothorax post WSD.

16days before refers to RSISA patient felt sudden stabbing pain in his
predominantly left chest area. He began to feel out of breath and both his respiratory
and heart rate increased dramatically after woken up when he had outwork shipping in
Pekalongan to Tegal. This dyspneu suddenly getting worst even he couldnt have a
walk. Because patients feel increasingly hard to breath even not able to have a walk,
patient has dropped to RS Kraton Pekalongan. Patient didnt do something streneous
activity before and didnt complain of bad cough even had a chest trauma before.

Patient had been hospitalized for 11days in RS Kraton Pekalongan and underwent a
WSD on the left side of chest and then have been refered to RSISA.

When he reffered in RSISA he felt discomfort on his chest followed hard to breath
even unable to walk activity as a previous complaint. Patient has been hospitalized to
Baitul Izzah 2 RSISA.
Patient has no history of chronic obstruction disease, TBC or any other lung disease
except paru bocor and had been underwent several therapy in RSISA and has no
family history of lung disease.

o History previous illness

HT :-
DM :-
Allergy :-
Asthma :-
COPD :-
Lung disease :+
Pneumothorax post WSD

o Familys history of disease

HT :-
DM :-
Allergy :-
Asthma :-
COPD :-
Lung disease :-

o Socio-economic history
Smoker half of pack for a day. Stopped after illness
Hospital cost certified by National Health Guarantee
Economic Impression : marginal
 C. Anamnesis sistemik
a. General : dyspneu
b. Skin : itching (-), jaundice (-), pale (-), slick (-)
c. Head : headache (-)
d. Eyes : blurred vision (-), red eyes (-), icteric sclera (-/-)
e. Ears : hearing loss (+), ring (-), discharge (-)
f. Nose : nosebleed (-), discharge (-)
g. Mouth : cyanosis (-), thrush (-), bleeding gums (-)
h. Throat : pain swallow(-), hoarseness (-), difficult in swallowing (-)
i. Neck : enlargement of the gland (-)
j. Chest : cough (+), sputum (-), blood (-), dyspneau (+)
k. Cardiac : chest pain (-), palpitations (-)
l. Digestive : abdominal pain (-), nausea (-), vomiting (-), black diarrhea (-)
more than 10 times a day, micsi (+)
m. Musculoskeletal: weak (+), rigid (-), back pain (-)
n. Extremity : oedema extremity (-)

I. PHYSICAL EXAMINATION
General Status
General : Dyspneu
Awareness: Fully Aware / Compos Mentis
Vital Sign
Blood Pressure : 150/100 mmHg
Heart rate : 80x/minute, regular ritmict, strong amplitudo, same equality,
pulsus alternans (-), pulsus defisit (-)
Breath Frequency : 36x/minute with NRM
Temp :36,1oC
Chest expansion : 1cm
 Lung examination

INSPEKSI ANTERIOR POSTERIR

Static RR : 36x/min, Hyper pigment RR : 36x/min, Hyper

(-), spider nevi (-), atrophy pigment(-),spider nevi (-),
Pectoral Muscle (-), Hemithoraks D=S, ICS
Hemithoraks D>S, ICS Normal, Diameter AP < LL
retractif, Diameter AP < LL

Dynamic Up and down of hemitoraks Up and down of hemitoraks

(N/<), abdominothorakal D>S, abdominothorakal
breathing, (+), muscle breathing (-), muscle
retraction of breathing (+), retraction of breathing (-),
retraction ICS (+) retraction ICS (-)

Palpation Palpable pain (-/+), tumor (-), Palpable pain (-), tumor (-),
Arcus costae angle < 900, Stem fremitus (N/<)
enlargement of ICS (-),
Sterm fremitus (N/<)

Percution Hipersonor (-/+) Hipersonor (-/+)

Auskultation Vesicular (N/<), Whezzing (-), Vesicular (N/<), Whezzing (-),

Ronchi (+/+) Ronchi (+/+)

Cor
Inspection : Ictus cordis wasnt seen.
Palpation : Ictuscordiswaspalpableat ICS V 2 cm lateralfromleft mid
clavicle line, thrill (-), epigastric pulse (-), parasternal pulse (-),
sternal lift (-).
Percussion : dull sound
Upper borderline of heart : ICS IIleft 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 V, 2 cm medial from left
mid clavicle line
 Auscultation
Aortal valve : S1 & S2 standard, additional sound (-),
SI<S2
Pulmonary valve : S1 & S2 standard, additional sound (-),
S1<S2
Tricuspid valve : S1 & S2 standard, additional sound (-),
S2>S1
Mitral valve : S1 & S2 standard, additional sound (-)
S2>S1

Abdomen
Inspection : symetric, sycatric(-), striae(-), enlarge - ment of vena (-
), caputmedusa (-) abdominal breathing
Auscultation : peristaltic (+) N
Palpation
o Superfisial : tight (-), massa (-)
o Deep : abdominal pain (-), liver, kidney, and spleen werent
palpable, Murphys sign (-)
Percussion : tympani, side of deaf (-), shifting dullness (-)
o Liver : deaf(+), right liver span 11 cm, left liver span 6 cm
o Spleen :Throbespace percussion (+) tympani
Extremity
 Hasil pemeriksaan laboratorium

Pemeriksaan radiologi

Kesan:

Cor tak membesar

Pneumothorax kiri luas curiga disertai efusi pleura minimal
(hidropneumothorax kiri) disertai kolaps paru kiri
Bula ukuran besar di hemithorax kanan DD/ - Localized pneumothorax
 Emfisema subkutis minimal pada hemithorax kiri
Tak tampak fraktur costa

DATA ABNORMALITAS

Anamnesis

referral from RS Kraton Pekalongan with pneumothorax post WSD

stabbing pain in his predominantly left chest

feel out of breath

his respiratory heart rate increased dramatically

dyspneu suddenly getting worst

not able to have a walk

have no streneous activity before

didnt complain of bad cough

have no chest trauma before

lung disease except paru bocor and had been underwent several therapy

Physical examination

Dyspneu

Tachypneu

Hipertension gr 2

Tachypneu Dyspneu

Asimetric chest dynamic

Muscle retraction

Palpable pain (-/+)

 Sterm fremitus (N/<)

Hipersonor (-/+)

Vesicular (N/<)

Ronchi (+/+)

Pemeriksaan penunjang

Laboratory:

Anemic

Hyperglicemic

Hypokalemia

Hyperchloride

Radiologic

Hidropneumothorax sinistra, Localized pneumothorax, Emfisema subcutis

Problem List

1. Hydropneumothorax sinistra
2. Hypertension Gr 2
3. Anemic
4. Hyperchloride
5. Hypokalemic

Diskusi

1. Hydropneumothorax
Ass : PSP, SSP, Efusi Pleura, Empyema
IP Dx : Chest X-Ray, PA
IP Tx : NRM 7lpm, Konsul bedah WSD
IP Mx : vital sign, Sp O2, distress respiration, BGA
 IP Ex : Tell about patients illness both to the patient or patients family, the etiology
of the disease, and explaining the goals of therapy

2. Hypertension Gr 2

Ass : Hypertensi Maligna and Benigna

IP Dx : Funduscopy

IpTx :

Non Pharmacology

Low salt dietary

Low fat dietary

High Fiber

Reduce hard activity

Pharmacology

Furosemid 40 mg 1 x 1

B-blocker, ARB maintenance CHF

IpEx:

Explain about the disease

Maintain weight and dietary

Avoid drink and eat too much salt

Mild Exercise at least 30 minute in everyday

Consumption drug regularly

3. Anemic

Ass :

Kadar Hb : ringan (9.7 g/dl)

 morfologi : hipokromik mikrositik, normokromik normositik, makrositik
etiopatogenesis : Anemia karena gangguan pembentukan eritrosit dalam
sumsum tulang, akibat perdarahan (akut), akibat hemolitik, Anemia dengan
penyebab tidak diketahui atau dengan patogenesis yang kompleks

IP Dx : DR, APD, MCV, MCHC, Reticulosit, Ferritin, TIBC, Fe serum, BMP, serum
B12, serum folat

IP Tx :

Medikamentosa

Fe 3-6mg/kgBB/ hari

Non medikamentosa

Identifikasi penyebab

Makan makanan tinggi protein dan tinggi Fe : daging merah, hati, telur

IP Mx : vital sign, syok hipovolemik, BGA, TIBC

IP Ex :

Tell about patients illness both to the patient or patients family, the etiology
of the disease, and explaining the goals of therapy

4. Hypokalemi
Ass : Kalium 2.77 mEq
penurunan asupan kalium
peningkatan laju kalium dalam sel
peningkatan kehilangan GIT
peningkatan kehilangan urin
peningkatan pengeluaran keringat
dialisis
IP Dx : Px lab: Kalium darah, kalium urine, HCO3, pH darah, osmolalitas, GDS,
IP Tx :
medikamentosa : -
non medikamentosa : pisang, kurma, alpukat, markisa, kentang
IP Mx : vital sign, EKG, kekuatan otot, vomitus
 IP Ex :
Tell about patients illness both to the patient or patients family, the etiology
of the disease, and explaining the goals of therapy

5. Hyperchloride
Ass :
-Dispnea
-Edemabernintik
- Takikardia, hipertensi
IP Dx : Elektrolit darah, pH, GDS, HCO3
IP Tx : infus RL 20tpm
IP Mx : vital sign
IP Ex :
Tell about patients illness both to the patient or patients family, the etiology
of the disease, and explaining the goals of therap