ADVISER DR. H. M. SAUGI ABDUH, SP.

PD

PATIENTS IDENTITY

Patient came to IGD with chief complaint was vomitus since 1 day ago. Patient had vomit 12 times. She also felt malaise, dizziness, jaundice, subfebrile, nausea, decrease in appetite and the colour of urine was dranker. She felt this complaints after she drank drug from her first be inpatient

Socio-economic history: Medical expenses incurred by Jamkesmas

Familys history of disease - The same symptomps (-) - TB pulmo (-)

Previous history illness - TB pulmo (+) - Hypertension (-) Diabetes mellitus (-) - Asma (-) - Allergy (-)

SYSTEMIC ANAMNESIS
General : weakness Skin : itching (-), jaundice (-), pale (-), slick (-) Head : headache (-) Eyes : blurred vision (-), red eyes (-/-), icteric sclera (+/+) Ears : hearing loss (-), ring (-), discharge (-) Nose : nosebleed (-), discharge (-) Mouth : cyanosis (-), thrush (-), bleeding gums (-) Throat : pain swallow(-), hoarseness (-), difficult in swallowing (-) Neck : enlargement of the gland (-) Chest : cough (+), sputum (-), blood (-) Cardiac : chest pain (-), palpitations (-) Digestive : decreased appetite(+), nausea (+), vomiting (+), defecate / micsi (+/+), urine colour is darker Musculoskeletal : weak (+), rigid (-), back pain (-) Extremity : oedem extremity (-)

PHYSICAL EXAMINATION
General Status General : weakness Awareness : composmentis Vital Sign Blood Pressure : 100/70 mmHg Heart rate : frequ. 76x/minutes, regural ritmict, strong amplitudo, same equality, elastic artery wall, pulsus alternans (-), pulsus defisit (-) Breath Frequency : 24x/minutes Temp : 36,5o C 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 (-), Oedem of upper extremity (-)

THORAX-LUNG
INSPEKSI Static ANTERIOR RR : 24x/min, Hyperpigmentation (-), spider nevi (-), atrofi M. Pectoralis (-), Hemithoraks D=S, ICS Normal, Diameter AP < LL Up and down of hemitoraks D=S, abdominothorakal breathing, (-), muscle retraction of breathing (-), retraction ICS (-) Palpation pain (-), tumor (-), enlargement of ICS (-), Stem fremitus S=D POSTERIOR RR : 24x/min, Hiperpigmentasi (-), spider nevi (-), Hemithoraks D=S, ICS Normal, Diameter AP < LL

Dinamic

Up and down of hemitoraks D=S, abdominothorakal breathing (-), muscle retraction of breathing (-), retraction ICS (-) Palpation pain (-), tumor (-), enlargement of ICS (-), Stem fremitus S=D

Palpation

Percution

Sinistra : redup Dextra : upper : redup; lower : sonor

Sinistra : redup Dextra : upper : redup; lower : sonor

Auskultati on

ronchi (+) S>D, wheezing (-)

ronchi (+), S>D wheezing (-)

Interpretation: ronki +, percussion redup infiltrat on both lung (S>D)

CARDIAC
Inspection Palpation Ictus cordis isnt seen Ictus cordis is palpable in ICS V 2 cm medial from linea mid clavicula sinistra, thrill (-), pulsus epigastrium (-), pulsus para-sternal (-), sternal lift (-) Upper borderline : ICS II linea sternalis sinistra Waist : ICS III linea parasternalis sinistra Lower right borderline : ICS V linea sternalis dextra Lower left borderline : ICS V 2 cm medial linea midclavicula sinistra Aorta valve : S1 & S2 standart, additional sound (-), AI<A2 Pulmonal valve : : S1 & S2 standart, additional sound (-), P1<P2 Tricuspidal valve : S1 & S2 standart, additional sound (-), T1>T2 Mitral valve : S1 & S2 standart, additional sound (-), M1>M2
Interpretation: normal

Percussion

Auscultation

INSPEKSI Symetric, sycatric(-), striae(-), scuama(-) enlargement of vena (-), hyperpigmentasi (-), spider nevi (-) PALPATION peristaltic (+) Normal (24 x/ minutes) PERCUTION side of deaf (-), shifting Hepar : deaf(+), liver span dextra 7 cm, liver span dullness (-), undulation(-) sinistra 5 cm

Lien
AUSKULTATION Superfisial : massa (-), abdominal pain (-)

: traube space perkusi dull sound

Deeper: abdominal pain (+), hypocondrium dextra and epygastrium hepar is not palpable, lien is not palpable, kidney is not palpable.

Interpretation: There are a process in hypocondrium and epygastrium

EXTREMITY
Ekstremity Oedem Cold akral Fisiologis reflect Superior -/-/+/+ Inferior -/-/+/+

Interpretation: normal

11

16 May 2012 Hematologi - Hemoglobin - Hematokrit - Leukosit - Trombosit

19 May 2012

Normal value

14,4 45,4 10,9 529

15,57 11,27 4,3 53 180 Negative 9,71 7,33 2,38 31 95

11,7-15,5 g/dL 33-45% 3,6-11 ribu/uL 150-440 ribu/uL

0,1-1,0 0-0,2 0-0,75 0-35 0-35 Negative

Kimia - Bilirubin total - Bilirubin direk - Bilirubin indirek - SGOT - SGPT Imunoserologi - HBsAg kualitatif

BTA sputum Sewaktu I (+) 2 Pagi (+) 2 Sewaktu 2 (+) 2

Interpretation:

Hyperbilirubinemia Increase of liver enzym (hepatosit inflamation) TB pulmo

Interpretasi : normal
18

INTERPRETATION

Interpretation: Cor : CPR <50% normal Pulmo: 1. Cloudiness both of USG: lung,upper and midlle right lung, middle and lower left size and structure of liver lung are normal 2. Cavitas in the middle left Renal, pancreas and lien are normal lung

 Vomitus, nausea Malaise, dizziness Subfebrile Jaundice Decrease in appetite Colour of urine is dranker

Physical examination
Weakness Icteric sclera Percussion lung : redup S>D Ronchi (+) both of lung S>D Abdominal pain (hypocondrium dex and epygastrium)

Hiperbilirubinemia Increase liver enzym TB pulmo X-photo thorax : cloudiness both of lung S>D; calsification hilus lymp

Advance examination

Anamnesa

PROBLEM LIST

Hyperbilirubinemia with jaundice TB pulmo Dyspepsia

HYPERBILIRUBINEMIA WITH JAUNDICE

Ass : o Intrahepatic (viral hepatitis, hepatitis drug induced) or post hepatic (kolesistitis, kolelithiasis, pankreatitis, pankreas cancer) Ip. Dx : o Imunoserology viral hepatitis; liver function test; amylase serum, ptotrombin time post giving vit K; USG Ip. Tx : Therapy based on the etiology Ip. Mx : Bilirubin concentration, jaundice, liver function test Ip. Ex : o Explain the cause of her complaint o Bed rest o Drink drug regularly

HEPATITIS
Ass : Hepatitis viral or non-viral Ip. Dx : Alanin and aspartat aminotransferase concentration, bilirubin, immunoserology test (IgM anti HAV, IgM anti HEV, HBsAg, anti HDV, anti HCV), fosfatase alkali and albumin concentration Ip. Tx : Inf. D5% 20 tpm Po : Curcuma 3x1 Vit B6 3x1 Urdahex 2x1

 Ip. Mx Bilirubin serum, alanin and aspartat aminotransferase concentration, albumin serum, fosfatase alkali concentration Ip. Ex : Explain about her disease Stop this firs inpatient drug if she gets complaints like them and consuls to the doctor Improvement of food and beverage hygieni Improvement of environmental

TBC

Ass Ip. Dx: Ip. Tx OATs First Category. Ip. Mx BTA sputum, Chest X-Ray

IP Ex

Explain about his disease Drink Drugs regularly Explain side effect of drugs The way of transmission close the mouth when get cough, where put the pleghm, and keep in family condition. Increase the good lifestyle STOP smoking Open the window and warm the bed on under shining sun day regularly Control to doctor regularly

DYSPEPSIA
Ass : Organic or functional dyspepsia Ip. Dx : Endoscopy, abdomen USG Ip. Tx : Inj. Pantoprazole 1A/day Po : antacyd liquid 3x1C Ip. Mx : The complaint Ip. Ex : Avoid spicy and sour food Avoid stress Eating on time