CASE BASED DISCUSSION

Diajukan Untuk Memenuhi Tugas Kepaniteraan Klinik dan Melengkapi Salah

Satu Syarat Menempuh Program Pendidikan Profesi Dokter
Bagian Ilmu Penyakit Dalam
Rumah Sakit Islam Sultan Agung Semarang

Disusun oleh:
Nadya Sahnaz
30101407260

Pembimbing:

dr. Lusito, Sp.PD

BAGIAN ILMU PENYAKIT DALAM

FAKULTAS KEDOKTERAN UNIVERSITAS ISLAM SULTAN AGUNG
SEMARANG
2018
 CASE REPORT

A. Patient Identity
 Name : Mrs. K
 Age : 36 years old
 Gender : female
 Religion : Islam
 Number of Medical record : 01-07-xx-xx

 Address : Demak
a. room : Baitul Izzah 1
b. status care : BPJS-NPBI

B. Data
1. Anamnesis
 Main Problem : Watery defecation

 History Taking
Pasien datang ke unit gawat darurat RSISA dengan keluhan buang air
besar berair. BAB cair dialami selama kurang lebih 3 hari. BAB cair
muncul setelah makan di Warteg kecil. Dalam sehari, pasien mengeluh
BAB cair sebanyak lebih dari 8 kali, sebanyak ½ gelas setiap kali pasien
mengalami BAB cair. Warna BAB cairnya seperti seperti cucian air beras
(-), lendir (-), darah (-), nyemprot (-). Pasien telah dirawat oleh dokter
keluarga tetapi belum pulih. Pasien juga mengeluhkan lemas, nyeri ulu
hati, dan juga mual dan muntah > 3x per hari.

 History of Previous Disease

 History of Previous Disease
 DM History :-
 Hipertention History :-
 Gastritis History :+
 DHF History :-
 Stroke History :-
 Heart Disease History :-
  Drug allergy :-
 Smoking :-

 History of Family Disease : HT (+)

 History of social-economy
BPJS NPBI

C. Systematic Anamnesis
 Chief Complain : Watery Defacation

 Onset : 4 days ago

 Kualitas : Patient feels weak and can’t going to work

 Kuantitas : More than 8 times per day

 Modification factor :

Aggravate : When patients doing activity

Amitigate : Resting
 Another Symptoms : Weakness, Nausea, Vomitus, Heartburn

D. Physical Examination
General Status : Weakness
Awareness : compos mentis

Vital Sign
 Blood Pressure : 90/60 mmHg
 Heart Rate : 123 x/menit
 Respiration Rate : 30 x/minute
 Suhu : 37,8 o C
Nutritional Status
◦ Antropometric status
Height = 165 cm and Weight = 55 kg
BMI = BB(kg)/TB²(m²) = 55 kg/(1,65 m)²
= 20,22 (normoweight)
 General Status
 General : Weakness
 Skin : gatal (-), pucat (-). Petekia (-) turgor <2 second
 Head : Headache (-), Dizzines (+)
 Eye : blurred vision (-/-), anemic conjungtiva (+/+),
sclera ikterus (-/-)
 Ear : Hearing disorder (-/-), discharge (-/-)
 Nose : simetris, nostril breath (-), epistaksis (-), discharge (-)
 Mouth : sianosis (-), tounge deviation (-), stomatitis (-).
 Throat : Hiperemis (-)
 Neck : trachea deviation (-), Tyroid hipertropy (-)
lymph hipertropy (-)
Thorax
Pulmo:
INSPECTION ANTERIOR POSTERIOR

Static RR : 30 x/min, Hiperpigmentasi RR : 30 x/min, Hiperpigmentasi (-),

(-), Hemithoraks D=S, ICS Hemithoraks D=S, ICS Normal,
Normal, Diameter AP < LL Diameter AP < LL
.

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

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

PALPATION Palpable pain(-), tumor (-), Arcus Palpable pain(-), tumor (-), Arcus
costae angle < 900, enlargement of costae angle < 900, enlargement of ICS
ICS (-), Stem fremitus decrease (-), Stem fremitus decrease (-)
(-)
 PERCUSSION Sonor Sonor

AUSKULTATIO Vesicular (+), Whezzing (-), Vesicular (+), Whezzing (-), Ronchi (-)
N Ronchi (-)

Cor :
INSPECTION
Ictus cordis isn’t seen

PALPATION
Ictus cordis is palpate at SIC VI 1 cm lateral linea mid clavicula sinistra
thrill (-) pulsus epigastrium (-), pulsus para-sternal (-), sternal lift (-)

PERCUSSION
- Upper borderline of heart : SIC II linea sternalis sinistra
- Waist of heart : SIC III linea para sternalis sinistra
- Lower right borderline of heart : SIC V linea sternalis dextra
- Lower left borderline of heart : SIC V, 2 cm medial from left
midclavicle line
AUSKULTATION
 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 (-)

Abdomen
INSPECTION

symetric, sycatric (-), striae (-), enlargement of vena (-), caput medusa (-)

AUSCULTATION
hiperperistaltic (+)  40x / minute
PERCUSSION

tympani, side of deaf (-), • Liver :deaf (+), right liver span 11 cm, left liver
shifting dullness (-) span 6 cm
: deaf (+), right liver span 11 cm, left liver span 6
cm

• Spleen: Throbe space percussion  tympani

PALPATION

Superfisial: Deep:
 tight (-), mass (-),  abdominal pain (-), liver, kidney, and spleen
epigastrial pain (+) weren’t palpable, Murphy’s sign (-)

Extremity

EXTREMITY Superior Inferior

Oedem -/- -/-
Cold Extremity +/+ +/+
Physiological reflex +/+ +/+

Pathological reflex -/- -/-

Sensibillity +/+ +/+

Advance examination
1. HEMATOLOGI
Pemeriksaan laboratrium Hasil Nilai Normal
4-09-2018
Hemoglobin 11,7- 15,5 g/dl
12,8 g/dl
Hematocrit 33 – 45 %
38,8 %
Leucocyte 3.8 – 11 ribu u/L
20,11 ribu/uL
Trombocyte 150 – 440 ribu/uL
283 ribu/Ul
Gol darah
O/positif
Ureum 10-50
18 mg/dL
Creatinin Darah 0,7 – 1,3
1.05 mg/dL
Natrium 135 - 147
145,7 mmol/L
Kalium 3,5 - 5
3,09 mmol/L
Chloride 95 - 105
103,8 mmol/L

E. Abnormality Data
ANAMNESIS
1. Watery defecation
2. Weakness
3. Heartburn
4. Nausea,vomiting
5. Past illness: Gastritis (+)

PHYSICAL EXAMINATION
6. 90/60 mmHg
7. 30 x/menit, cepat, dalam
8. 37.80C
9. N : 123 x/menit
10. Hiperperistaltic (40x/ minute)
11. Epigastrial pain (+)
12. Cold extremity (+)

C. LABORATORY EXAMINATION
13. Leukositosis
14. Hypocalemia

F. Problem List
- Acute Gastroenteritis
- Gastritis
- Hypocalemia

G. Problem List Discussion

 1. Acute Gastroenteritis
Assesment :
Emergency : Shock hipovolemik, severe dehidration
DD : GEA ec bacteria, GEA ec virus, GEA ec parasite, GEA ec fungi
IP Dx :
- Feses rutin (makros dan mikros)
- Kultur feses
- Analisa gas darah
IP Tx :
1. Ciprofloxacin 2 x 500 mg (5-7 hari)
2. Attapulgite 4 x 2 tablet atau 2 tablet setiap BAB, maks : 12 tablet

3. Rehidrasi : Skor daldiyono

Skor : rasa haus/muntah, hipotensi, takikardi, akral dingin  4

1,46 L = 1.460 ml

TPM : = 243,3 tpm  243 tpm (habis dalam 2 jam)

1.460 ml cairan diberikan dalam 2 jam pertama.
Rehidrasi berikutnya berdasarkan kehilangan cairan melalui tinja dan IWL
Ip. Mx :
1. Vital sign : sistolik > 90, Nadi kuat angkat,
2. Urin tampung : > 0,5- 1 ml/kgBB/jam
 BB : 55 kg = 27,5 – 55 ml/jam
Ip. Ex :
1. Banyak minum air
2. Mengetahui tanda dehidrasi
3. Bed Rest

2. Gastritis
Assesment
Komplikasi akut : Perdarahan saluran cerna, perforasi lambung
DD : Ulkus peptik, GERD, Ulkus duodenum
IP Dx :
-Urea Breath Test
-Endoscopy
-PPI Test
IP Tx :
Antasida 3 x 500 mg
Lansoprazole 2 x 30 mg
Sucralfate Syr 3 x 1C
Ip. Mx : -
Ip. EX :
 Tidak makan makanan yang dapat merangsang pengeluaran asam lambung
seperti makanan yang pedas, asam, kopi.
Makan teratur, tepat waktu, makan sering dengan porsi kecil

3. Hypocalemia
Assesment
Komplikasi : Aritmia
IP Dx :-
IP Tx :
-KSR 3 x 600 mg
Ip. Mx :
1. Vital sign
2. EKG
3. Kadar kalium
Ip. EX :
-Diet tinggi kalium