San Rio Tonapa

Department of Internal Medicine

Faculty of Medicine
University of Hasanuddin
2018
 VISI

Menjadi pusat pendidikan yang unggul, mandiri, dan

bermartabat untuk menghasilkan dokter spesialis
penyakit dalam yang berkualitas dan mampu bersaing
secara regional, nasional maupun global pada tahun
2020, dengan didukung oleh sumber daya manusia yang
professional dan bertanggung jawab.
 MISI

1. Menyelenggarakan pendidikan di bidang ilmu penyakit

dalam berbasis evidence based medicine dan riset
2. Memberikan pelayanan kesehatan di bidang ilmu
penyakit dalam dengan pendekatan kultural dan
budaya secara paripurna dan bermutu
3. Meningkatkan kuantitas dan kualitas penelitian dasar
dan aplikatif ilmu penyakit dalam yang bertaraf
internasional
4. Menciptakan sistem maanajemen program studi ilmu
penyakit dalam yang transparan, akuntabel,
responsibel, independen, terintegrasi, dan berkeadilan
 Name : Ms M
 Age : 62 years old
 Address : Makassar
 Occupation :
 Religion : Christian
 Ethnic : Toraja
 Marrital Status : Married
 Hospital : Hassanudin University Hospital
 Room : 4th floor
 Registry Number : 086537
 Date of Admission : 16/2/2018 (17.00)
 Date of Death : 25/02/2018(03.00))
 Shortness of breath is felt since 1 week ago that
weighed 1 last day, history of shortness of breath
since 1 month ago. shortness of breath is felt lost,
burdensome activity, such as walking to the bathroom
and improving at rest. Ordinary patients wake up at
night due to spasms, and sleep on 2 pillows. Chest
pain is present, felt since 1 day ago. Chest pain such
as heavy objects, the patient has a history of high
blood pressure since last 1 year and consumes
irgansartan 150 mg once daily, furosemide 40 mg
once daily and taken regularly.
Patients also had a history of heart disease in October
2017 admitted to the hospital and said to be enlarged
from the heart, the patient was given furosemide 40
mg with a dose once a day. Fever has no history of
fever does not exist, headache has been felt since 3
days ago history of headache since 2 weeks ago there.
No blurred vision, no cough, no cough history. No
swallowing pain.
Patients complain the body feels weak appetite
decreased patients since last 3 months, there is weight
loss of approximately 5 kg. Patients often feel
nauseated, no vomiting. Patients urinate volume
decreased in the last 1 yellow color and sometimes
yellow like tea. No pain during urination, no history
of sandy urination. Patients have difficulty defecating
since the last 5 days, the history of defecation is no
black color, the history of defecation mixed with
blood does not exist.
 Patients complained of swelling in both legs and arms
since less than 1 week ago, a history of swollen limbs
existed, in October last year. Patients also suffered from
diabetes mellitus suffered since less than 10 years ago,
patients routinely taking drugs, diamicron 30 mg once
daily history of insulin drug use in 2016 due to the
patient often felt weak, and the patient's increased
weight at that time
 History kidney disease in October 2017
 No history of liver disease
FAMILY HISTORY
 Mother :Died, cause of death is unknown
 Father :Died, cause of death is unknown
 Siblings :Second child from 5. No history of
similar disease from patients siblings.
 No history of smoking and alcohol consumption.

 No history of consuming herbal medicine.

 GENERAL DESCRIPTION:
- Impression : Moderately illness
- Nutritional Status : Well Nourished
- Consciousness : GCS15 E4M6V5
- Body Weight : 45 kg
- Body Height : 150 cm
- BMI : 18 kg/m2
 VITAL SIGNS:
- Blood pressure : 140/80 mmHg
- Pulse : 96 tpm
- Respiratory rate : 24 tpm
- Axillary tempt. : 36.7 oC
 HEAD:Normocephal, black hair that not easily
pulled out

 EYES: Conjunctiva pale. Sclera not icteric. No

oedema of palpebral. Pupil is symmetrical, with
diameter of 2mm/2mm, positive for light reflex.

 NECK : JVP R+4 cmH2O (elevation of 30).

Thyroid gland and lymph nodes are not palpated.
 THORAX EXAMINATION:
- Inspection : Both hemithorax movement is
symmetrical.
- Palpation : Vocal fremitus symmetrical on
both hemithorax.
- Percussion : Resonance sound on both
hemithorax. Liver flatness sound is positive.
- Auscultation : Bronchovesicular breath sound
with rales on basal bilateral.
 HEART EXAMINATION:
- Inspection :Ictus Cordis is not visible
- Palpation :Ictus Cordis 2 fingers lateral to left
midclavicular line
- Percussion :Left heart border on 6th ICS 2
fingers lateral to left midclavicular
line. Right heart border on 4th ICS
perpendicular to right
parasternal line.
- Auscultation :The I-II heart sound pure, regular,
no gallop, no murmur
 ABDOMINAL EXAMINATION:
- Inspection : Flat, follow the breathing motion,
no tumor mass
- Auscultation : Normal peristaltic sound
- Palpation : The liver and spleen not palpable,
No tenderness, no tumor mass,
no epigastric tenderness
- Percussion : Tympani, no shifting dullness