Department of Internal Medicine

Faculty of Medicine Sultan Agung Islamic University

2019

Case Based Discussion

Aisyah
30101407123
Advisor :
dr. H. M. SAUGI ABDUH, Sp.PD., KKV, FINASIM
Patient Identity
Name : Mr. S
Age : 58 y.o.
Gender : Male
Religion : Moslem
Job : Unemployed
Address : Dusun Karang Tengah 03/03, Sumur Gede, Godong,
Grobogan
MR number : 01380276
Room : Baitul Izzah 1
Entry date : May 17rd, 2019
Date out : March 21th, 2019
History taking
Main Problem
• Abdomen enlargement

History of present illness

• Patient came into the emergency department in Islamic
Hospital of Sultan Agung Semarang, complained about
abdominal enlargement since 3 days before entered hospital.
His abdomen grew bigger and bigger everyday and pain in
the upper mid quadrant of abdomen (epigastric pain). Patient
also complained about nausea, watery diarrhea and
decreased appetite since 3 days before entered hospital. His
lower extremity is swelling that make unable to walk. Because
of his abdominal enlargement more bigger day by day, his
family took him to hospital.
 HISTORY OF ILLNESS
HISTORY OF PREVIOUS ILLNESS
Hypertension history (-) FAMILY’S HISTORY OF DISEASE

DM history (+) Family who has the same illness (-)

Heart dissease history (-) Hypertension history (-)
Kidney disease history (-) DM history (-)
Gastritis (-)
Allergy history (-)
• SOSIO-ECONOMIC HISTORY :
Alcohol consumption (-)
Tranfusion (-) • Hospital cost certified by

Hepatitis history (+) “BPJS-non PBI”

SISTEMIC ANAMNESIS
Chief Complains : abdomen enlargement

Onset : 3 days before entered hospital

Location : entire abdomen

 Chronology : Patient has abdominal enlargement with pain
the upper mid quadrant of abdomen (epigastric pain) suddenly since 3
days before entered hospital.

Quality and Quantity : His abdominal enlargement is more bigger day

by day

Modification factor : Better when he took a rest

Comorbid complains : Nausea, watery diarrhea, decreased appertite,

swelling in lower extremity
PHYSICAL EXAMINATION
GENERAL STATUS
BMI (Body Mass Indeks)
weight : 60 kg BMI= 60/(1.65 x 1.65) = 22
Hight : 165 cm Intepretation :
Normoweight

General : look weak

Awareness : Fully Aware / Compos Mentis (GCS=15)

Vital Sign

• Blood Pressure : 120/60 mmHg

• Heart rate : 100 x/minute

• Breath Frequency: 20 x/minute

• Temp : 37,4 oC Intepretation : Normal

GENERAL STATUS
Head : Mesocephal, alopesia (-)

 Eyes : Anemic Conjunctiva (+/+), Icteric sclera (+/+)

 Nose : symmetric, secret (-), Nostril Breath (-)

 Ears : Normal Shape, discharge (-/-)

 Esophagus : Hyperemic (-),

 Mouth : Cyanosis (-), dry lips (-),

 Neck : Trakhea deviation (-), Lymph Hypertropy (-)

 Extremity : upper extremity (-/-) / Oedem of lower extremity (+/+)

Intepretation : icteric sclera, anemic

conjungtiva, oedem of lower extremity
 Intepretation :
LUNG EXAMINATION NORMAL
INSPEKSI ANTERIOR POSTERIOR

Static RR : 20x/min, Hyper pigment (-), atrophy RR : 20x/min, Hyper pigment

Pectoral Muscle (-), Hemithoraks D=S, ICS (-) atrophy perctoral muscle (-) Hemithoraks D=S,
Normal, Diameter AP < LL ICS Normal, Diameter AP < LL

Dynamic Up and down of hemitoraks D=S, Up and down of hemitoraks D=S,

abdominothorakal breathing, (-), muscle abdominothorakal breathing (-), muscle retraction
retraction of breathing (-), of breathing(-),
retraction ICS (-) retraction ICS (-)

Palpation Palpable pain(-), tumor (-), Arcus costae Palpable pain (-), tumor (-), Arcus costae angle <
angle < 900, enlargement of ICS (-), Stem 900, enlargement of ICS (-), Stem fremitus D=S
fremitus D=S Sonor
Percution Sonor

Auskultation Vesicular (+), Whezzing (-), Ronchi (-) Vesicular (+), Whezzing (-),
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 V, 2 cm lateral from left
mid clavicle line
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 :
CARDIOMEGALY
ABDOMEN EXAMINATION
Inspection : convex of surface, sycatric(-), striae(-), caput medusa (-),
spider nevi (-)
Auscultation : peristaltic (+)
Percussion : tympani, undulation test (+), shifting dullness (+)
• Liver : cannot be assessed
• Spleen : cannot be assesed
Palpation :
• Superfisial : tight (+), mass (-), epigastric pain (+)
• Deep : epigastric pain (+), liver, kidney, and spleen weren’t
palpable

Intepretation : ascites
EXTREMITY EXAMINATION
Ekstremitas Superior Inferior

• Oedema -/- +/+

• Cold -/- -/-

• Jaundice -/- +/+

Intepretation : oedem and jaundice in the

lower extremity
Laboratorium Examination
 17/05/2019 18/05/2019 19/05/2019 21/05/2019 Normal values
Haemoglobin 7,9 (L) 9,2 (L) 13,2 – 17,3 g/dL
Hematocrit 23,4 (L) 27,8 (L) 33 -45 %
Leukosit 3,39 (L) 7,48 3,8 – 10,6 ribu/uL
Trombosit 89 (L) 71 (L) 150 – 440 ribu/Ul
Ureum 86 (H) 10 – 50 mg/dl
Blood creatin 0,88 0,7 – 1,3 mg/dl
SGOT 153 (H) 0-50 U/l
SGPT 79 (H) 0-50 U/l
GDS 200 (H) 322 (H) 70-110 mg/dL
Total bilirubin 12,07 (H) 0,1 – 1,0 mg/dl
Direct bilirubin 7,32 (H) 0 – 0,2 mg/dl
Indirect bilirubin 4,75 (H) 0 – 0,75 mg/dl
Total protein 5,29 (L) 6,0 – 8,0 mg/dl
Albumin 1,75 (L) 2,10 (L) 3,4 – 4,8 g/dl

Globulin 3,54 2,5 – 3,5 %

HBsAg Kualitatif reaktif Non reaktif
Intepretation : anemia, leucocytopenia, thrombocytopenia, uremia, elevated SGOT and
Natrium 130,4 (L) 135-147 mmol/L
SGPT, hyperbilirubinemia
Kalium
(total, direct, indirect), hypoalbuminemia, hyponatremia,
7,82 (H) 3,5-5 mmol/L
hyperkalemia, hypochloremia,
Chloride 92,0hiperglikemia,
(L) low total protein 95-105 mmol/L
18/05/2019 X Foto Thorax
18/05/2019

1. Less inspiration
2. Cor : apex to laterocaudal
3. Pulmo : bronchovasculer pattern increased and dense
dim pattern in upper lung and perihilar dextra and sinistra
4. Diaphragma very high
5. Sinus costophrenicus no abnormalities appear

Intepretation :
Cardiomegaly suspect
Bronchopneumonia appearance
 Abdomen 2 position (non contrast)
18/05/2019
18/05/2019 1. Pre peritoneal fat line dextra and sinistra dim

2. Psoas line and kidney contour dextra and sinistra dim

3. Distribution of air inintestine gathered in the middle, in LLD

projection it moves to lateral hemiabdomen

4. Not visible distension and dilatation intestines

5. Not visiblle coiled spring image and herring bone appearance

6. Not visible air in cavum pelvis

7. Not visible opasitas patholaogist image in cavum abdomen and

cavum pelvis

8. On LLD projection, not visible multiple air fluid level and free air
Intepretation :
Ascites appearance
No ileus and pneumoperitoneum appearance
19/05/2019 USG Abdomen
1. Size of liver was smaller, with edge irreguler-microbulated and
elevated exogenity parenchym inhomogen, suitable with hepatis
cirrhosis appearance

2. Splenomegaly, parenchym homogen

3. Not visible dilatation of porta vein and lienalis vein

4. Ascites, debris (+)

5. Sonomorphology other intraabdominal organ within normal line

Intepretation :
Hepatis chirrosis
Splenomegaly
Ascites
RHYTM : Sinus rhytm
REGULARITY : Regular
FREQUENCY : 107 x/minute
P WAVE : t=0,08, l=0,08 (Normal)
PR INTERVAL : 4 x 0,04 = 0,16 (Normal)
QRS COMPLEX : 0,06 s (normal),
ST SEGMENT : no ST depression or ST elevation
T wave : no T tall, T flat, T inversion
TRANSITION ZONE: V3
AXIS : Lead I (+) and aVF (+) : normo axis deviation
Intepretation :
Sinus tachycardia
Abnormal Data 16.
Laboratory :
Anemia
Physical Examination 17. Leucocytopenia
History Taking
7. Icteric sclera 18. Thrombocytopenia
1. Abdomen 19. Uremia
8. Anemic conjungtiva
enlargement 20. Hyperbilirubinemia
9. epigastric tenderness
2. Epigastric pain (total, direct, indirect)
10. Oedem in the lower
3. Nausea 21. Elevated SGOT and
extremity
4. Swelling lower SGPT
11. Jaundice in the lower
extremity 22. Hypoalbuminemia
extremity
5. Decreased appetite 23. Hyponatremia
12. Cardiomegaly
6. Watery diarrhea 24. Hyperkalemia
13. Convex of surface
abdomen 25. Hypochloremia
14. Undulation 26. Hyperglicemia
Thorax X-Ray 15. Shifting dullness 27. Low total protein
28. Cardiomegaly
29. Broncopneumonia USG
appearance 31. Hepatis chirrhosis
BNO 32. Splenomegaly
30. Ascites 33. Ascites
 Problem List
1. Hepatis Cirrhosis
(1,2,3,4,5,7,9,10,11,12,13,14,15,17,18,20,21,22,23,24,25,27,28,30,31,32,33)
2. Ascites (1,13,14,15,30,33)
3. Diarrhea (6)
4. Anemia (8,16)
5. Diabetes mellitus (26)
6. Hypoalbuminemia (22)
7. Hiperkalemi
8. Broncopneumoni
9. Hyponatremi
10.Trombocitopeni
• Ass : IP.Mx : Awareness, vital sign, rapid weight
Risk factor  alcohol, substance abuse, tattoos gain/loss, abdominal pain, hematemesis
Complication  esophageal varices, Ca melena, fever, oliguria/anuria
hepatocellular, hepatorenal syndrome,
hepatopulmonary syndrome, spontaneous
bacterial peritonitis
IP.EX :
• IP.Dx : Biopsy liver, hepatitis serologies, APTT  Explain about the disease
HbeAg, HbV DNA,  Maintain weight
• IP.Tx :  Healthy diet
Non Farmacology :  Reduce water and salt
• Bedrest  Consumption drug regularly
• Diet low salt (2 mg/daily), limit fluid intake
Farmacology :
Curcuma 2 x 1
Inj. Komafusin hepar 1x1
Assessment :  Ip.Mx :
DD: ascites caused by liver disease, heart failure, Vital sign
nephrotic syndrome, cancer, tuberculosis
associated with porta hypertension and non porta Weight and abdominal circumference
hypertension output of fluid level (total urin 24
complication : spontaneous bacterial peritonitis, hours)
Grade 1,2,3
Elektrolit
IpDx : Culture, Rivalta test, albumin –globulin level
Albumin level, protein total
Ip Tx :  Ip. Ex :
Non Farmacology
Bedrest  Diet low salt
Reduce the input of salt (2mg/daily) Just take food from the hospital
Farmacology
Consumption drug regularly
Spironolacton 1 x 100 mg
Furosemid 1x40 mg
Cefuroxime inj. 2x1 A
Assessment :
DD : diarrhea acute ec rotavirus, diarrhea acute IP Mx : general status, vital sign,
ec fungi, diarrhea acute ec bacteria dehydration sign, diarrhea (frequency
Complication : paralitic ileus, dehydration and consistency)
Risk factor : poor hygiene IP Ex
•Explain about disease
IpDx : feses routine, culture feses, •bedrest
Ip Tx : •Maintaining higienity
Non Farmacology specifically hand,
Bed rest environment, sanitation, clean
Rehidration water
Intake nutrition •Drink medicine regularly
Pharmacology
infus RL 20 tpm
Attalpulgit 2 tablet @600 mg each diarrhea
Inj. Lansoprazole 2x1 A (30mg)
L-Bio 1x1
 Ip Tx :
Non Farmacology
Eat nutrition regularly
Assessment :
DD : Anemia ec chronic disease, Anemia hemolytic, Diet high Fe
Anemia defisiensi folat / vit.B12, anemia Transfusion blood
hemorrhagic,
anemia normocytic normochromic, anemia Pharmacology
macrocytic hypercromotic, anemia microcytic PRC 2 kolf
hypochromic Sulfas Ferrosus 3 x 200 mg
Vit. C 3 x 100 mg
IpDx : erytrocyt index (MCV, MCH, MCHC), blood
As. Folat 3 x 1
smear, reticulocyte count, serum iron concentration and
TIBC, serum feritin, G6PD test, bone marrow aspiration
IP Mx : general status, hematology
and bone marrow biopsy
routine post transfusion,

IP Ex
Explain definition and caused of
anemia
Explain to eat food nutrious regularly
Take medicine regularly
Assessment : IP Mx :
Complication : Microangiopathy = retinopati diabetic, general status, vital sign, monitoring GDP,
nephropathy diabetic . GDS, blood chemical
Macroangiopathy = ulcus diabetic, coronary heart
disease, peripheral arterial disease, Neuropathy, IP Ex :
Cerebrovaskular disease Before insulin injection, prepare food or
tea for eat after injection so that not
IpDx : Funduscopy, Angiography, Elektromiogram, CT fainted
Scan head Follow the healthy menu that were
advised
Ip Tx : Use insulin injection according to
Non Pharmacology prescribtion
healthy diet low sugar

Pharmacology
Metformin 2x 500mg
Insulin rapid acting (Humalog) 3 x 10 unit
 Assessment : -
IpDx : -
 IpTx :
 Non Pharmacology :
- Diet high protein 1,5 gr/kgBB/day
 Pharmacology :
Inf. D5% 20 tpm
Albumin Correction : (Alb target – Alb actual) x BB X 0,8 = (3,5-2,10) x
60 x 0,8 = 67,2 gram  25 % each 100 ml
 Ip.Mx : Albumin level
 Ip Ex : consumption high protein food (egg)