CBD

Case Base Discussion

Advisor : dr. H. M. Saugi Abduh, Sp.PD, KKV, FINASIM

Oleh : RAKHA FAHREZA
 Name : Mr. P
Age : 48 years old
Gender : Male
Religion : Moslem

Patient Job
Address
: swasta
: Semarang
Identity MR number : 0134xxxxx
Room : Baitul Izzah 1
Entry date : October 22th, 2018
Date out : October 23 th, 2018

2
 History of Present Illness

48-year-old male patient came to Emergency

room of RSISA. He lost his awareness. Before
Main Problem came to hospital, he eat Hot spicy rica-rica. He
had diarhea more than 5 times a day. The
diarhea had not stop until he came to hospital.

Decrease of The family said that the diarhea count was

much, more than 5 times and the quality was
fluid, dark (black color) sometimes. He had
Awareness never been like this before. He had’nt eat drug
before. He had another complication such
thirsty, decrease of eating, headache, nausea,
that causes patient have no appetite.
3
 Onset
1 1 days before

Location
Systemic 2 All over the abdomen

Anamnesis 3
Chronology
Eat rica- rica-> diarhea

Quality and Quantity

4 Fluid , dark (black), >5x, 250 ml per time
Decrease of
Modification factor
5 -
Awareness Comorbid complains
6 thirsty, decrease of eating, headache, nausea,
that causes patient have no appetite.
4
 HISTORY OF PREVIOUS ILLNESS SOCIO-ECONOMIC HISTORY

FAMILY HISTORY

Hypertension (-) Hypertension history (-)

Hospital cost certified by
DM (-) DM history (+)
“BPJS-non PBI”
Alkohol (-) Heart disease (-)
Allergy (-) Gastritis (+)
Heart disease (-)
Gastritis (+)
Smoking (-)
Astma -
5
 PHYSICAL
EXAMINATION

6
General Status
Awareness : CM (GCS 15)
Antropometri :
◦ Weight : 60 kg

◦ Height : 160 cm

◦ BMI : 60 : 2,56 = 23,437 INTERPRETATION :

normal
7
 In Emergency Room In Baitul Izzah
o BP : 120/74 mmHg o BP : 120/90 mmHg
o HR : 105x/menit o HR : 120x/menit
o RR : 22x/minute o RR : 24x/minute
o Temp : 37,5o C o Temp : 37,5o C

VITAL SIGN
INTERPRETATION : INTERPRETATION :
NORMOTENSION, NORMOTENSION,
TACHYCARDI TACHYCARDI
GENERAL PHYSICAL EXAMINATION
General
Skin : itching (-), jaundice (-), pale (+), slick (-)
Head : headache (+)
Eyes : blurred vision (-), red eyes (-), icteric sclera (-/-), con. Anemis(+)
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 (-), Dyspneu (-)
Cardiac : chest pain (-), palpitations (-)
Digestive : epigastrik pain (+), nausea (+), vomiting (-)
Musculoskeletal : weak (-), rigid (-), back pain (-)
Extremity : inferior extremity oedem (-/-)
 Lung Examination
INSPEKSI ANTERIOR POSTERIOR
Ad urbanitas argumentum sea. Ut has tota ridens oblique, ad elitr aliquam

Static RR : 24x/min, Hyper pigment (-), spider neivy

mentitum his. Duo in sale audiam incorrupte. Sea at accusamus rationibus,
RR : 24x/min, Hyper pigment
ad saepe facilis cum, convenire consequat conceptam est ne.

Quas invidunt ad nam, his reque molestiae te. Nam cu definitiones

definitionem, et oblique detracto electram nec.
1
(-), atrophy Pectoral Muscle (-), Hemithoraks D=S, (-), spider nevi (-), Hemithoraks D=S,
ICS Normal, Diameter AP < LL ICS Normal, Diameter AP < LL
2
Dynamic Up and down of hemitoraks D=S, abdominothorakal Up and down of hemitoraks D=S, abdominothorakal
breathing (-), muscle retraction of breathing (-), breathing (-), muscle retraction of breathing(-),
retraction ICS (-)3 retraction ICS (-)

Palpation Palpable pain(-), tumor (-), Arcus costae angle < Palpable pain (-), tumor (-), Arcus costae angle <
4 Expantion
900, enlargement of ICS (-), Chest 900, enlargement of ICS (-), Chest Expantion
(normal), Stem fremitus D≠S (normal), Stem fremitus D≠S (normal)

Percussion sonor 5 sonor

Auskultation Vesicular (+), Whezzing (-), Ronchi basal(-/-) Vesicular (+), Whezzing (-), Ronchi basal(-/-)

INTERPRETATION : normal 10
Inspection : Ictus cordis isn’t seen.
Palpation : thrill (-), epigastric pulse (-), Auscultation
parasternal pulse (-), sternal  Aortal valve : S1 & S2 standard, additional
lift (-). sound (-)
Percussion : timpani sound  Pulmonary valve: S1 & S2 standard, additional
- Upper borderline of heart: ICS II left sternal line sound (-)
- Waist of heart : ICS III left parasternal line
 Tricuspid valve : S1 & S2 standard, additional
- Lower right borderline of heart : ICS V right
sound (-)
sternal line
 Mitral valve : S1 & S2 standard, additional
- Lower left borderline of heart : ICS V 1 cm
sound (+)
from left mid clavicle line

INTERPRETATION :
Normal 11
 Abdominal Examination

INTERPRETATION :
Inspection
Abdominal Pain
bulging(-), hyperpigmentation (-), sycatric(-), striae(-),
vein distention (-), caput medusa (-).

Auscultation
peristaltic (+) 30x/menit=normal

Percussion
Timpani (+), side of deaf (-), shifting dullness
(-)
•Liver : dullness (-), right liver span 9 cm, left
liver span 6 cm
•Spleen : Traube space percussion (+)
Palpation
•Superfisial :
tight (-), mass (-), epigastrial pain (-)
•Deep : abdominal pain in epigastrium (+), liver (-) and
spleen palpable (-) renal (-) Murphy’s sign (-)
12
 EXTREMITY SUPERIOR INFERIOR
Oedem -/- -/-
Cold -/- -/-
Physiology Reflex +/+ +/+
Pathology Reflex -/- -/-
Icteric -/- -/-

INTERPRETATION :
Normal
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LABORATORIUM

14
 HEMATOLOGY
Hematology Nilai rujukan Keterangan
Hemoglobin I 8,5 13,2-17,3 g/dl Low
Hemoglobin II 10,7 13,2-17,3 g/dl Low
Hemoglobin III 11,8 13,2-17,3 g/dl Low
Hematokrit 35,5% 33-45% Normal
Leukosit 29,21 3,6-11ribu/uL High
Trombosit 367 150-440 ribu/uL Normal
Ureum 113 10-50 High
Creatinin 1,24 0,7-1,3 Normal

INTERPRETATION :
Anemia, leukositosis, high ureum
 BLOOD CHEMISTRY
Kimia Nilai rujukan Keterangan

Natrium 142,4 135-147 mmol/L normal

Kalium 3,97 3.5- 5 mmol/L normal

Chloride 95,7 95 – 105 mmol/L normal

INTERPRETATION: normal
17
USG

18
ECG

21
 Interpretation
Rhytm : Sinus
17/9/18 Regularitas : Reguler
Frekuensi : 115x/menit
Axis : NAD
Zona Transisi : V3
Gelombang P : t:0.2, l:0,08
Interval PR : 0,08
Komplek QRS : 0,04 s ( normal ),
Gelombang Q :-
Segmen ST : ST normal
Gelombang T : T normal

INTERPRETATION :
SNR takikardi
History Taking 8. Gastritis
Abnormal Data
1. Diarhea History
2. Nausea 9. Thirsty
3. Epigastric
pain Lab
4. Loss weight
10.Leukositosis
5. loss appetite
11.Anemia
6. weak
7. Fever

Physical Examination
15.Conjunctiva anemis
16.Pale skin
17.Thirsty mouth
18.Deep palpation pain in
X-RAY
epigastrium
22. Mild fatty liver
19.Dark faeces
20.Takhikardi
21.Urin output normal
Problem List
MILD FATTY
GEA LIVER

1,2,3,4,5,6,7,8, 9, 10,19 22

ANEMIA MELENA

11,16,17 20
 GEA

1. Assessment : Pharmacotherapy :
Etiology:
Attapulgite 3x1
Bacterial
Virus Ciprofloxacin 2x1 iv , 5 4. Initial Plan of Monitoring
Amoeba days
vital sign, electrolite
Parasit
Complication: Mild- 5. Initial Plan of Education :
Severe dehidration
2. Initial Plan of
Avoid risk factors , dont eat the
Diagnosis : - extreem food and rough texture
3. Initial Plan of Therapy
Non pharmacotherapy :
Bedrest,
RL infuse
 Melena Blood Transfussion continued
Sucralfat syr 100ml 3x1
1. Assessment : 2. Initial Plan of
Etiology: Diagnosis : Antasid
Endoscopi GIT
Tukak duodenum
Radiograph by barium Ocreotide 25mcg/jam selama 8-24 jam
Gastritis ulseratif et Vassopressin +nitrat
causa OAINS 4. Initial Plan of Monitoring
Radionuclid
Tukak duodenum BUN ECG, vital sign, Hematollogy routine
Varises Oeshophagus 3. Initial Plan of Therapy (HB serial), Tild Test, Forest
Ca Gaster Pharmacotherapy : Clasification,
Esophagitis 5. Initial Plan of Education :
Mallory weiss syndrom Reducing Emotional stress
Complication: Mild- Routine consumption drugs
Severe dehidration
Avoid risk factors
 MILD FATTY LIVER

1. Assessment :
DD:
Alcoholic
Non- alcoholic 4. Initial Plan of Monitoring
2. Initial Plan of Diagnosis : -
Biopsi hepar
5. Initial Plan of Education :
SGOT
Decrease Weight
SGPT
Profil Lipid
3. Initial Plan of Therapy
Ursodeoxycholic acid 13-15 mg/ hari
Vit E300 IU/ day
 IP Tx
ANEMIA
ASSESSMENT IP Dx Non farmacology :
-
Farmacology
› Index eritorsit • Blood transfusion  PRC 2
› Peripheral Blood Smear kolf. If Hb 7-9
Morphology
• Hipokrom
Mikrositer IP Mx IP Ex
• Normokrom
normositer • Bed rest/ restriction of physical
• Vital sign activity
• Hb status • Explain about Anemia
• Thrombocyte status • Explain about treatment of anemia
• Reaction of transfusion • Explain about side effect of
anemia’s treatment
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