CBD

CASE BASE DISCUSSION

Bayu Robie Wibisono

012065146

Advisor

dr.Lusito Sp.PD

Patients Identity

Nama
: ny. P
Umur
: 35 th
Jenis kelamin : Perempuan
Agama
: Islam
No. Medical Record : 01246517
Alamat
: Ngablaksari RT 3/8 sayung, Demak
Ruang rawat : Baitul Izzah 1
Tgl masuk
: 28 Januari 2017
Tgl keluar
: 30 Januari 2017
Status Care
: JKN non PBI

HISTORY TAKING
Keluhan Utama

Riwayat
Penyakit

Muntah
Pasien merasa mual dan muntah
selama 2 hari sebelum masuk
rumah sakit, pasien juga mengeluh
adanya mencret sehari 4 x BAB,
konsistensinya cair tidak ada lendir.
Pasien sudah periksa ke dokter
keluarga BPJS tapi keluhan tidak
kunjung sembuh. Akhirnya pasien
dibawa ke IGD RSISA Semarang
,

SISTEMIC ANAMNESIS
Main Complains
: Muntah
Onset
: 2 Hari Yang Lalu
Location
:Chronology
: Pasien merasa mual dan muntah selama 2 hari
sebelum masuk rumah sakit, pasien juga mengeluh adanya mencret
sehari 4 x BAB, konsistensinya cair tidak ada lendir. Pasien sudah
periksa ke dokter keluarga BPJS tapi keluhan tidak kunjung sembuh.
Akhirnya pasien dibawa ke IGD RSISA Semarang
Quality and Quantity : : muntah sehari 5x, sampai mengganggu
aktivitas
Modification factor
: tidak muntah jika tidak makan
Comorbid complains : Mual, lemas

HISTORY OF ILLNESS
Family History Of Disease
Hypertension history (-)
DM history

(-)

Dispepsia history

(-)

Smoking
Cancer history

(-)
(-)

Liver Disease History (-)

Alcholic History

(-)

PHYSICAL EXAMINATION
General
: Weakness
Skin
: itching (-), redness (-), jaundice (-), pale (-)
Head
: headache (-)
Eyes
: blurred vision (-), red eyes (-), icteric sclera (-/-).
Ears
: hearing loss (-), tinitus (-), discharge (-)
Nose
: nosebleed (-), discharge (-), nostril breath (-)
Mouth
: cyanosis (-), thrush (-), caries (-)
Throat
: pain swallow (-), hoarseness (-), difficult in swallowing (-)
Neck
: enlargement of the gland (-)
Chest
: pain (-),cough (-), sputum (-), blood (-)
Cardiac
: chest pain (-), palpitations (-)
Digestive : abdominal pain (-), nausea (+), vomiting (+), defans muscular (-)
Musculoskeletal
: weak (-), rigid (-).
Extremity
: oedem lower extremity (-/-)

GENERAL STATUS
BMI (Body Mass Indeks)
BMI (Body Mass Indeks)
Weight: 55kg BMI=55: 1,65 = 20,2
Weight: 55kg BMI=55: 1,65 = 20,2
High : 165cm
High : 165cm

General : Weakness
General : Weakness
Awareness : Weak / Compos Mentis
Awareness : Weak / Compos Mentis
Vital Sign
:
Vital Sign
:
Blood Pressure
: 125/77 mmHg
Blood Pressure
: 125/77 mmHg
Heart rate : 103 x/minute
Heart rate : 103 x/minute
Breath Frequency : 20 x/minute
Breath Frequency : 20 x/minute
Temp : 36,5o C
Temp : 36,5o C

Intepretation :
Intepretation :
NormoWeight
NormoWeight

LUNG EXAMINATION
INSPEKSI

ANTERIOR

POSTERIOR

Static

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

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

Pectoral Muscle (-), , ICS Normal, Diameter AP <

Hemithoraks D=S,

LL

ICS Normal, Diameter AP < LL

Up and down of hemitoraks D=S,

Up and down of hemitoraks D=S,

abdominothorakal breathing, (-), muscle

abdominothorakal breathing (-), muscle

retraction of breathing (-),

retraction of breathing(-),

retraction ICS (-)

retraction ICS (-)

Palpable pain(-), tumor (-), enlargement of ICS

Palpable pain (-), tumor (-), Stem

(-), Stem fremitus (+/+)

fremitus Decrease (-)

Percution

Sonor (+)

Sonor (+)

Auskultation

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

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

Dynamic

Palpation

CARDIAC EXAMINATION
Inspection : Ictus cordis (-)
Inspection : Ictus cordis (-)
Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-)
Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-)
sternal lift (-).
sternal lift (-).
Percussion
: dull sound
Percussion
: dull sound
Upper borderline of heart : ICS II left sternal line
Upper borderline of heart : ICS II left sternal line
Waist of heart : ICS III left parastern line
Waist of heart : ICS III left parastern line
Lower right borderline of heart : ICS V right sternal line
Lower right borderline of heart : ICS V right sternal line
Lower left borderline of heart : ICS V 2 cm medial midclavicula
Lower left borderline of heart : ICS V 2 cm medial midclavicula

line
line

CARDIAC
...CONT
Auscultation
Auscultation
Aortal valve : S1 & S2 standard, additional sound (-)
Aortal valve : S1 & S2 standard, additional sound (-)
Pulmonary valve : S1 & S2 standard, additional sound (-)
Pulmonary valve : S1 & S2 standard, additional sound (-)
Tricuspid valve
: S1 & S2 standard, additional sound (-)
Tricuspid valve
: S1 & S2 standard, additional sound (-)
Mitral valve
: S1 & S2 standard, additional sound (-)
Mitral valve
: S1 & S2 standard, additional sound (-)

ABDOMEN EXAMINATION
Inspection : symetric, enlargment (-), sycatric (-), striae (-),enlargement of vena
Inspection : symetric, enlargment (-), sycatric (-), striae (-),enlargement of vena
(-),
(-),
caput medusa (-), plakat eritematous with soft skuama (-)
caput medusa (-), plakat eritematous with soft skuama (-)
Auscultation
: peristaltic (-)
Auscultation
: peristaltic (-)
Palpation :
Palpation :
Superfisial : tight (+), mass (+), abdominal pain (-)
Superfisial : tight (+), mass (+), abdominal pain (-)
Deep
: abdominal pain (-), enlargement liver (-), kidney, and
Deep
: abdominal pain (-), enlargement liver (-), kidney, and
spleen palpable (-), Murphys sign (-)
spleen palpable (-), Murphys sign (-)
side of deaf (+), shifting dullness (+)
side of deaf (+), shifting dullness (+)
Percussion
Percussion
Liver
: deaf (+), right liver span 10 cm, left liver span 6 cm
Liver
: deaf (+), right liver span 10 cm, left liver span 6 cm
Spleen
:Throbe space percussion (+)
Spleen
:Throbe space percussion (+)

EXTREMITIES EXAMINATION

Ekstremitas Superior
Inferior
Ekstremitas Superior
Inferior

Oedema
-/Oedema
-/
Cold
-/-/Cold
-/-/
Jaundice
-/-/Jaundice
-/-/-

-/-/-

LAB. EXAMINATION
28/01/2017

Hematology

Hb

14,6 g/dl

Ht

43.9 %

Leukosit

9.98 ribu/uL

Trombosit

228 ribu/Ul

28/01/2017

widal

Sal. Paratyphi B O

Positif 1/160

Sal. Paratyphi B H

Positif 1/320

Natrium

140,0 mmol/L

Kalium

3,30 mmol/L

Chloride

107,1 mmol/L

ECG

Interprestasi

Irama : Sinus
Regularitas : Reguler
Frekuensi : 80 x/ menit
Axis : Normo Axis Deviation
Zona Transisi : V3
Gelombang p : 0,2 MV and 0,08 s
Interval PR : 0,16 s
Komplek QRS : 0,04 s
Gelombang Q : Normal
Segmen ST : isoelectric
Gelombang T: Normal
Kesan : normo Sinus

Abnormal Data

History
Taking
1. Abdominal
Pain
2. Weak
3. Nausea
4. Vomiting
5. Black
defecate

Physical
Examination
6. Icteric sclera
7.Shifting dullness
8. Abdominal Pain
Upper Right
Quadran
9.Oedem lower
extremity
10. Jaundice
11. Hepatomegaly

Abnormal Data
USG Abdomen
12. Hepatomegali dengan massa di sebagian lobus kanan dan kiri
hepar ukuran sekitar 8.9x11.6x7.3, curiga hepatoma
13.Asites

ECG :
14. Sinus takikardi

Abnormal Data
Laboratory finding
Hb 9,0 g/dl
Hematokrit 24.9%
HBsAG Reaktif
SGOT 614 IU
SGPT 152 IU
Albumin 2,44 g/dL
Natrium 126,5 mmol/L

Result
15. Liver Function Increase
16. Hepatitis B
17.Hiponatremia

PROBLEMLIST
LIST
PROBLEM
1. Carcinoma Hepatoseluler
1. Carcinoma Hepatoseluler
2. Ascites
2. Ascites
3. Hepatitis B
3. Hepatitis B
4. Hiponatremia
4. Hiponatremia

1. Hepatocelullar Carcinoma

Assessment : Hepatitis B Chronic

Intial Plan Of Diagnostic : AFP, Foto Thorax, CT

SCAN/MRI

Abdomen,

Liver

Biopsy,

Direk,Indirek dan Total

Initial plan of therapy

Non Pharmacology

Pharmacology
MST 2x10 mg

O2 2-4 Lpm

Curcuma 3x1

Bed Rest

Lanzoprazol 2 x 1
Inf RL 20 tpm

Bilirubin

Initial Plan of Monitoring:

- Vital Sign, KU, Liver Function Test.

Initial Plan Of Education :

-Educate the patient about the disease

- Educate the patient about the prognostic of the
disease
- Educate the patient to reduce consuming fat food
- Educate the patient to eat the food that contain high
protein and carbohydrate.

Karnofsky Score = 70

ECOG/ WHO Score = 2

2. HEPATITIS B
Assesment : Hepatocellular carcinoma
Initial Plan of Diagnostic :
AFP
Anti HBs, Anti HBc, HBeAg, Anti HBe,
Immunoserology test Ig M anti HBc, Ig G anti HBc

Initial Plan of Therapy:

Farmakologik
Kelompok imunomodulasi
Interferon
Timosin alfa 1
Kelompok terapi antivirus
Lamivudin
Adefovir Dipivoksil
-

Curcuma 3x1

Initial Plan Of Monitoring :

Vital sign, keadaan umum, liver function test, blood test
Initial Plan of Education :
a. Pada hepatitis B kronis karena pengobatan cukup lama, keluarga
ikut mendukung pasien agar teratur minum obat.
b. Pada fase akut, keluarga ikut menjaga asupan kalori dan cairan
yang adekuat, dan membatasi aktivitas fisik pasien.
c. Pencegahan penularan pada anggota keluarga dengan modifikasi
pola hidup untuk pencegahan transmisi, dan imunisasi.

3. ASCITES
Ass :

Transudat
Eksudat
IP Dx : Rivalta Test, Albumin, Globulin
IP Tx :
Spironolakton 100 mg 1x1
Furosemid 20 mg 1x1

Initial Plan of Monitoring:

- Physyical Exam : circum waist, Weight,
Shifting Dullness
- electrolite
Ip Ex :

- Reducing eat & drinks that containing salt

- Bed rest

4. Hiponatremia
Ass :
Initial plan Dx :
Initial Plan Tx :
Natrium Correction
(140-126.5)x55x0,6 =444,5 mEq/L need 500cc
NaCl 0.9%(154mmol) 3 plabottle. (462mmol)
Initial Plan Mx :
Monitoring Chemical Blood Test
Initial Plan Ex :

Educate the patient about the condition,

TERIMAKASIH