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. Lusito, Sp.PD

BAGIAN ILMU PENYAKIT DALAM

FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM SULTAN AGUNG
SEMARANG
2013
 ANAMNESIS

Patients identity
Name : Mrs. EM
Age : 40 years old
Sex : Female
Religion : Moslem
Adress : Pondok Raden Patah III K/9 Sayung Demak
No. CM : 105 14 39
Ward : Baitul Izzah 1 (410.5)
Status : Social health insurence
Check in : 13.2.2013
Check out : 18.2.2013

Main problem
Coughing up blood

History of present illness

Onset : since two weeks ago
Location : throat, lungs
Frequency : several times
Quality : red fresh blood
Quantity : a cup leatherback
Modification factor : by rest there was no improvement
Other complains : chest pain, lost of appetite, headache, weakness

History of past illness

H. Similiar complaint : denied
H. Hypertension : denied
H. DM : denied
 H. Maag : denied
H. Asthma : denied
H. Drug allergy : denied
H. Tbc : denied

Familys illness history

No similiar family complains
Daughters patient suffering from tuberculosis

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 (-/-)
Ear : 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 = 140/100 mmHg
HR = 76 x/menit
RR = 20 x/menit
T = 36,3 oC
BMI
BB = 40 Kg
TB = 150 cm
Impression :
Vital sign (stage 1 hypertension)
BMI 17,7 (underweight)

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: 20 x/min, hyperpigmentation (-), RR:20x/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 Sonor Sonor
AUSCULTATION ronchi (-) wheezing (-) vesikuler (+) ronchi (-) wheezing (-) vesikuler
(+)
IMPRESSION NORMAL

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
side of deaf (-), shifting
Hepar : deaf (+), liver span dextra 9 cm, liver span
dullness (-), undulation
sinistra 5 cm
(-)
Lien : traube space perkusi dull sound

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

Extremity

Ekstremity Superior Inferior

Oedem -/- -/-

Cold akral -/- -/-

Fisiologis reflect +/+ +/+

Ikteric -/- -/-

Impression NORMAL
 ECG

Rhythm : reguler
Frequency :1500 : 17kk = 88 x/menit
Axis : NAD
Transition zone : V3
P wave : 0,4 sec
QRS complex : 0,12 sec
PR Interval : 0,16 sec
ST Segment : elevation (I, II, aVL, V3, V4, V5, V6)
T wave : 0,16 sec
Impression : infark miokard

RO Thorax (2013, 13th February Lungs TB)

 2013, 13th February
Examination Result Unit Normal value

Hematology

Hemoglobin 15 g/dl 11,7-15,5

Hematocrit 41,4 % 33-45

Leukocyte 6,84 (L) Thousand/uL 3,6-11,0

Platelet 267 Thousand/uL 150-440

Blood group/ Rh B/ positive

2013, 15th February

Microbiology
P. BTA (sputum) S1 = Negative Negative

Abnormalitas data
History taking
1. Coughing up blood
2. Chest pain
3. Loss of appetite
4. Headache
5. Weakness
6. Daughters patient suffering from tuberculosis
7. Nausea
 Physical examination
8. BP: Stage 1 hypertension
9. BMI: Underweight
Laboratory result
10. ECG: Infark miokard
11. RO Thorax: Lungs TB
12. Leukocyte 6,84
Lungs TB (1, 2, 3, 4, 5, 6, 7, 9, 11)
HT grade 1 (2, 8, 10)

Lungs TB

IPAss
Tbc primer, Tbc secunder
IPDx
sputum BTA, bacterial culture, RO Thorax
IPTx
Non-farmacology : diet TKTP , bed rest
Farmacology :
R/ OAT FDC category 1 S 1ddIII
R/ Aminophilin 100 mg tab S 3ddI
R/ Codein 20 mg tab S 2dd1
R/ Ceftriaxone inj. 2 gr S imm
R/ Asam tranexamat inj. S imm
R/ Ondancetron inj 4 mg S imm
IPEx
open the window for getting sirculation and sunshine to reduce humidity, diet TKTP ,
bed rest, regular medication, dont spit carelessly, closes mouth by hand when coughing
or sneezing
IPMx
 Vital sign, weight, sputum BTA, RO Thorax

HIPERTENSION Grade 1

IPAss
HT primer et secunder
IPDx
ECG, funduscopy, RO Thorax
IPTx
Non-farmacology
Bed rest, diet salt , exercise healthy heart
Farmacology
R/
IPEx
Dont hard work, drinking coffee , exercise healthy heart, regurlarly control bp, regular
medication
IPMx
Vital sign, ECG

Follow Up
Date BP HR RR T S O A P
Couhing up
blood, chest Sputum BTA S1,
Hemoptoe,
140 36,3 pain, ECG, routine blood
13.2.2013 76x 20x HT grade
100 oC weakness, lab, RO Thorax, diet
1
headache, TKTP salt
nausea
130 36,3 Sputum BTA P1,
14.2.2013 80x 20x Cough Tbc, HT
90 oC diet TKTP salt
15.2.2013 140 84x 20x 36,7 Headache, Tbc, HT Sputum BTA S2,
100
oC nausea, chest grade 1 diet TKTP salt
 pain
Headache,
140 36 Tbc, HT Diet TKTP salt
16.2.2013 80x 20x nausea, chest
90 oC grade 1
pain
120 36, Diet TKTP salt
17.2.2013 81x 20x Cough Tbc, HT
90 oC
120 36,2 diet TKTP salt
18.2.2013 80x 20x No complaint Tbc, HT
90 oC ,