CASE BASE

DISCUSSION
HILMAN SUHAILI
01.211.6410

ADVISOR :
DR. H. M. SAUGI ABDUH, SP.PD., KKV, FINASIM
DEPARTMENT OF INTERNAL MEDICINE
MEDICAL SCHOOL OF SULTAN AGUNG ISLAMIC UNIVERSITY
2016

Name

: Mrs. K

Age

: 37 years old

Gender

: Female

Religion

: Moslem

Job

: Factory Employee

Address

: KP. Kisik Sari RT 04/01 Semarang

MR number

: 01-08-88-12

Room

: Baitul Izzah 1 402.1

Entry date

: 18 july 2016

Date out

: 23 july 2016

HISTORY TAKING

HISTORY OF ILLNESS
HISTORY OF PREVIOUS ILLNESS
Hypertension history (-)
DM history

HISTORY :

(-)

Hospital cost certified

Asthma history

(-)

Alergy history

(-)

FAMILYS HISTORY OF DISEASE

Hypertension history (-)
DM history

(-)

Asthma history

(-)

Alergy history

(-)

SOSIO-ECONOMIC

by
JKN NON PBI

SISTEMIC ANAMNESIS
Main Complains

: Abnormal breathing (dyspneu)

Onset

: 2 days ago

Location

: Chest, feel hard to breath.

Chronology :Patien felt hard to breath when she rest.

Quality and Quantity : Hard to breath everytime and
disturbing activities.
Modification factor

: He felt better when a half sitting position.

Comorbid complains

: Weak, productive cough, wheezing during

breathing, chest as tied whole body redness

with
itching

PHYSICAL EXAMINATION
General

: dyspneu,weaknes

Skin

:itching(+),redness (+),jaundice(-),pale(-), slick (-),

Head

:headache(-)

Eyes

:blurredvision(-),red eyes(-),ictericsclera(-/-)

Ears

:hearingloss(-),ring(-),discharge(+/-)

Nose

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

Mouth

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

Throat

:painswallow(-), hoarseness(-), difficult in swallowing(-)

Neck

: enlargement ofthe gland(-)

Chest

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

Cardiac

:chest pain(-),palpitations(-)

Digestive

:abdominal pain (-),nausea(-), vomiting(-)

Musculoskeletal

:weak(+),rigid(-),back pain (-)

Extremity

: oedem extremity (-) plakat eritematous with soft skuama (+)

GENERAL STATUS
BMI (Body Mass Indeks)
weight

: 160

High

: 52

General

BMI=52: 1,67 = 20,3

Intepretation :
Normo Weight

: Dyspneu

Awareness : Fully Aware / Compos Mentis

Vital Sign

Blood Pressure

: 110/70 mmHg

Heart rate

: 80 x/minute

Breath Frequency
Temp

: 28 x/minute

: 37,6oC

Intepretation : -

GENERAL STATUS
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 / upper extremity (-) / (-)

plakat eritematous with soft skuama (+)

Intepretation : Asthma, OMSK,

Viral Exhantema

LUNG EXAMINATION

CARDIAC EXAMINATION
Inspection

: Ictus cordis isnt 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 parastern 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(-), plakat eritematous with soft

skuama (+)

Auscultation

: peristaltic (+) normal

Palpation

Superfisial

: tight (-), mass (-)

Deep

: abdominal pain (-), liver, kidney, and spleen

werent
Percussion

palpable,
: tympani, side of deaf (-), shifting dullness (-)

Liver

: deaf(+), right liver span 11 cm, left liver span 6

Spleen

: Normal
:Throbe spaceIntepretation
percussion (+) tympani

cm

EXTREMITIES EXAMINATION
Ekstremitas

Superior

Inferior

Oedema

-/-

-/-

Cold

-/-

-/-

Jaundice

-/-

-/-

LAB. EXAMINATION
1/6/2016

Hematologi

1/6/2016

Imunoserologi

Hb

15,3 g/dl

HbsAg

Non reaktif

Ht

45,1%

Leukosit

11,64 ribu/uL

Trombosit

319 ribu/uL

GDS

--

27/10/2015

Kimia

Natrium
Kalium
Chloride

138.9
mmol/L
3.98mmol/L
107,9 mmol/L

Intepretation :
Leukositosis
Hypercholeremia

X-RAY THORAX
Intepretation :
1.Cor : Bentuk dan letak normal
2.Pulmo : corakan vascular
meningkatan, tampak infiltrat di
parakardial kanan kiri.
Diafragma setinggi kosta 11 posterior.
Sinus costofrenicus kanan kiri suram.
KESAN:
Gambaran Bronkopneumonia
Efusi pleural minimal

IRAMA

: Sinus rhytm

REGULARITAS : Regular
FREKUENSI

: 83x/16 = 93menit

GELOMBANG P : 2 x 0,04 = 0,08 (Normal)

PR INTERVAL

: 4 x 0,04 = 0,16 (Normal)

QRS COMPLEX : 2 x 0,04 = 0.08 (Normal)

ST SEGMEN

: 4 x 0,04 = 0,16 (Normal)

GELOMBANG T : Normal
ZONA TRANSISI : V3
AXIS

: Lead I (-) dan aVF (-)

: LAD

Intepretation : normal

Abnormal Data
Physical
History Taking
1. Dyspneu, 2.weak
3.Productive cough,
4.Wheezing, 5.chest
as tied 6. Whole
body redness, 7.
itchig

Examination
8. Otorhea, 9.
nostril breath, 10.
plakat eritematous
with so skuama,
11.dimmed in the
llung bases
12. Muscle
retraction of breath
13. ronchi

Ro Thoraks :
14.Bronchopneum
oni picture
15. Minimal
pleural effusion

Lab
Hematology
16. leukositosis
17. Hypercholeremia

PROBLEM LIST
1

BRONCHITIS
ASTHMA
(1,
2,3,4,5,9,12)

BRONCHOPNE
UMONIA
( 1,3,13,14,16)

VIRAL
EXANTHEMA
( 6,7,10)

PLEURAL
EFFUSION
( 15)

OMSK
(8)

1. Bronchitis Asthma
Ass: - Bronchitis acute and Bronchitis Chronic Exacerbataions Acute
- Asthma Exacerbations Acute
- Chronic Obstruction Pulmonal Disease
- Bronchiektasis
IP Dx : Spirometri (Peak Flow Meter (APE), Skin test

IP Tx :
Non Pharmacology
-02 nasal canul 3L/minute
-Consumtion of nutrisions
foods.

Pharmacology
Ventolin 5mg & fulmicort 1 resp
(Nebulizer) 15-20 minute
Inj. Aminophilin 3x1 amp
Inj. Dexamethason 2x1 amp (5mg)
OBH syr 3 x 1 C

Ip. Mx : Vital sign, oxygen saturation, Spirometri, blood routin test

Ip. EX :
Explain the patients illness
Avoid smoke exposure
Consumption of nutrisions food
Routine consumption drug
Avoid of greasy food (mendoan, bakwan, kacang goreng,dll)
Use brochodilator before exercise

PIGEON CHEST/pectus carinatum

Sternum distal
melengkung ke
anterior, bagian
lateral dinding torax
kmpresi ke median
(seperti dada
burung).
Etiologi : Ricketsia,
kelainan kongenital

FUNNEL CHEST/fectus excavatum

Bagian distal dari
sternum terdorong
kedalam/mencekung.
Etiologi : penyakit
ricketsia/congenital

FLAT CHEST
Diameter
anteroposterior
memendek.
Etiologi :
bilateral pleuro
pilmonary
disease.

Barrel chest
Diameter anterposterior
memanjang dengan ciri:
1. iga melebar
2.Sudut epegastrium
tumpul
3. Iga mendatar
4. Diagragma mendatar.
Etiologi : PPOK

PEMERIKS
AAN

INSPEKSI

PALPASI

PERKUSI

BRONKITIS

ASMA

-Simetris
Tidak ada penggunaan
-Retraksi intercosta
otot bantu nafas
- Penggunaan otot
Diameter
bantu nafas (+)
Anteroposterior <
Diameter
Transversal (normal)
Anteroposterior <
Transversal

Strem fremitus normal

Pengembangan dada
normal

Sonor

AUSKULTA
Vesikuler normal
SI
Ronchi negatif

Strem fremitus
normal
Pengembangan
dada menurun

PPOK

Wheezing
Vesikuler normal
Ronchi negatif

Retraksi intercosta
- Penggunaan otot
bantu nafas (+)
Pergeseran
Mediastinum ke arah
paru yang terkena
Diameter
Anteroposterior <
Transversal

Penggunaan otot
bantu nafas (+)

Diameter
Anteroposterior =
Transversal

Strem fremitus
menurun
Pengembangan
dada menurun

Sonor

Barrel Chest (Sela

iga melebar, iga
mendatar, sudut
epiggastrium
tumpul, diafragma
mendatar)
-

BRONKIEKTAS
IS

Hipersonor

Wheezing
Vesikular
melemah/menurun
Ronchi basah

Strem f remitus
menurun
Pengembangan
dada menurun
Redup pada bagian
dilatasi

Wheezing
Vesikuler normal
Ronchi basah

PEMERIKSA
AN

BRONKITIS

ASMA

PPOK

Batuk
berdahak,
Manifestasi
-Sesak(terutama
sesak
(+/-),
demam
Klinis
malam hari),
(bila
akut),
nyeri

-batuk , mengi,
otot,
sakit
kepala

dada seperti diikat

Pemeriksaa Darah Rutin

n
penunjang

Spirometri
Darah lengkap

Sesak napas,
batuk kronis,
produksi sputum
kronis

Spirometri

BRONKIEKTASIS
Sesak, batuk
berdahak (>3bln),
hemoptisis,
penurunan BB,
mialgia, mengi,
nyeri dada pleuritik

Radiologi
thoraks
Ct- Scan

Peak flow meter

2. BRONCHOPNEUMONI
Ass : Pneumonia ( Community aquired pneumoni, Nosocomial aquired pneumoni )
spesifik : m. tuberculosis
Non spesifik : diplococus pneumonia, pneumococcus pneumonia, klabsiella pneumonia,
haemophylus influenzae, staphylococcus aureus, streptococcus pneumonia
Ip Dx : Cultur bacteria, sputum examination

Ip Tx :

Non Pharmacology :
Consumption of nutrisions food
Oxigen 2-3 L/ Minute with nasal canul
Physiotherapi (Postural Drainage).

Pharmacology :
Infus RL 20 tpm
Cefuroxime 2 x 1 gr iv

- Ambroxol syr 3x 1 C

Ip. Mx : Vital Sign , X-Ray, Routine Blood Test.

Ip.Ex :
Education for prevention of recurrent infections
Consumption nutrisions food, vegetable, and fruit
Routine consumption drugs

3. PLEURAL
EFFUSIONS
Ass: Transudat effusion, Exudat effusion (e.c. Bronchopneumoni).

IP Dx :Light criteria, and rivalta test

IP Tx :IP Mx : Monitoring symptoms, thoracic physical examination & Vital sign

IP Ex : Bedrest, avoid overactivity

4. Viral Exhanthema
Ass

: Morbili, Rubella

IP Dx : -

IP Tx : consul skin specialist

Farmacology :
-Isoprinosin 3x1
-Betametason cr 5mg

-Soft u derm cr I

 Non Pharmacology :-

Ip.Ex :
The wound should not be card

5. OMSK
Ass : OMA, OE

Ip Dx : Otoschopy

Ip Tx : Consul to ENT specialist

Non Farmakologis

TERIMAKASIH