CBD

CASE BASE DISCUSSION

Okky Winang Saktyawan

012116481

Advisor :

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

 Patients Identity
Name : Mr. B

Age : 49 years old

Gender : Male

Religion : Moslem

Job :

Address : Wonorejo RT 09/02 GUNTUR DEMAK

MR number : 01301813

Room : Baitul Izzah 1 409.6

Entry date : November 24th, 2016

Date out :, 2016

 HISTORY TAKING
Patient Problem Abdominal pain

Patient came into the Policlinic

of Islamic Hospital of Sultan
Agung Semarang Complained
History of about his abdominal pain about
Present Illness 3 weeks ago especially in
upper right quadrant. In early,
The problem just feel appear
and disappear, but 7 days
lately, the pain continues and
never stop, and worsen 2 days
before went to the Hospital.
HISTORY OF ILLNESS
Family History Of Disease
Hypertension history (-)
DM history (-)
Dispepsia history (-)
Smoking (+)
Cancer history (+) Lung Cancer
Liver Disease History (-)
Alcholic History (-)
FAMILYS HISTORY OF DISEASE
Hypertension history (-)
DM history (-)
Carcinoma history (+)Lung
Cancer
Hepatitis History (-)
SOSIAL-ECONOMY
Hospital cost certified by
JKN Non-PBI
SISTEMIC ANAMNESIS
Main Complains : Abdominal paint
Onset : 21 days ago
Location : Upper right quadrant
Chronology : He complained that 21 days ago He feel pain
in upper right quadrant. In early, The problem
just feel appear and disappear, but 7 days
lately, the pain continues and never stop, and
worsen 2 days before went to the Hospital.
Quality and Quantity : Patient feel paint in his abdomen
everytime and
disturbing activities.
Modification factor : He never felt better.
Comorbid complains : Dyspneu, Nausea, Vomit, Black
defecate, Felt his abdomen bigger than usual.
PHYSICAL EXAMINATION
General : dyspneu (+),
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 (+) lower right quadrant ,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 : 66kg BMI=66: 1,65 = 24,2
weight : 66kg BMI=66: 1,65 = 24,2
High : 165cm
High : 165cm Intepretation :
Intepretation :
NormoWeight
NormoWeight
General : Dyspneu
General : Dyspneu
Awareness : Weak / Compos Mentis
Awareness : Weak / Compos Mentis
Vital Sign :
Vital Sign :
Blood Pressure : 110/70 mmHg
Blood Pressure : 110/70 mmHg
Heart rate : 103 x/minute
Heart rate : 103 x/minute
Breath Frequency : 26 x/minute
Breath Frequency : 26 x/minute
Temp : 36,5o C
Temp : 36,5o C
LUNG EXAMINATION
INSPEKSI ANTERIOR POSTERIOR

Static RR : 26x/min, Hyper pigment (-), spider, atrophy RR : 26x/min, Hyper pigment (-),
Pectoral Muscle (-), Hemithoraks D=S, ICS 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 of breathing (-), retraction of breathing(-),
retraction ICS (-) retraction ICS (-)

Palpation Palpable pain(-), tumor (-), enlargement of ICS Palpable pain (-), tumor (-), Stem
(-), Stem fremitus Decrease (+)right fremitus Decrease (-)
hemithoraks

Percution Sonor (+)

Sonor (+)
Auskultation Vesicular (+), Whezzing (-), Ronchi (-) Vesicular (+), Whezzing (-), Ronchi (-)
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 VI, mid clavicula
Lower left borderline of heart : ICS VI, mid clavicula
 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 paint (+)
Superfisial : tight (+), mass (+), abdominal paint (+)
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 15 cm, left liver span 10 cm
Liver : deaf (+), right liver span 15 cm, left liver span 10 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
23/11/2016 Hematology 24/11/2016 Hematology
Hb 15,6 g/dl Hb 12,3 g/dl

Ht 48,9 % Ht 39,4 %

Leukosit 6,50 ribu/uL Leukosit 14,66 ribu/uL

Trombosit 295 ribu/Ul Trombosit 409 ribu/Ul

23/11/2016 Kimia 24/11/2016 Kimia

Ureum 28 mg/dL Ureum 55 mg/dL

Creatinin darah 0,71 mg/dL Creatinin darah 1,39 mg/dL

SGOT 340 mg/dL SGOT 499 mg/dL

SGPT 54 SGPT 75

LDH 306
LAB. EXAMINATION
24/11/2016 Kimia
24/11/2016 Imunoserologi
Uric Acid 6,9 mg/dL
HbsAg Kualitatif Non-reaktif
Total Protein 7,05 g/dL

Albumin 2,44 g/dL 24/11/2016 Imunoserologi

GDS 95

Globulin 4,61 g/dl

Natrium 133,1 mmol/L

Kalium 5,2 mmol/L

Chloride 103,6 mmol/L

Kalsium 9,6 mmol/L

ECG
 Interprestasi
Irama : Sinus
Regularitas : Reguler
Frekuensi : 103 x/ menit
Axis : Normo Axis Deviation
Zona Transisi : V3
Gelombang p : Normal
Interval PR : Normal
Komplek QRS : Normal
Gelombang Q : Normal
Segmen ST : Normal
Gelombang T: T inverted di V1-V3
Kesan : Sinus Takikardia with anterior Ischemic
X-RAY THORAX
 Intepretation :
Intepretation :
1. Cor : Batas kanan jantung tidak jelas
1. Cor : Batas kanan jantung tidak jelas
2. Pulmo : corakan pariu tak meningkat, tampak bercak di pericardial kiri.
2. Pulmo : corakan pariu tak meningkat, tampak bercak di pericardial kiri.
Tampak opasitas bulging di lapangan bawah hemithoraks kanan berbatasan dengan
Tampak opasitas bulging di lapangan bawah hemithoraks kanan berbatasan dengan
diafragma kanan . Hemidiafragma kanan setinggi costa 8 posterior, kiri setinggi costa 10-11
diafragma kanan . Hemidiafragma kanan setinggi costa 8 posterior, kiri setinggi costa 10-11
posterior. Sudut costophrenicus kanan kiri lancip. Costa dan clavicula baik.
posterior. Sudut costophrenicus kanan kiri lancip. Costa dan clavicula baik.

KESAN:
KESAN:
Cor : Tidak dapat dievaluasi
Cor : Tidak dapat dievaluasi
Diafragma kanan letak tinggi
Diafragma kanan letak tinggi
DD/ Hepatomegali
DD/ Hepatomegali
Subpulmonal fluid collection
Subpulmonal fluid collection
Subphrenic lession
Subphrenic lession
Opasitas bulging di lapangan bawah hemithoraks kanan
Opasitas bulging di lapangan bawah hemithoraks kanan
DD/ Masa paru
DD/ Masa paru
Subpulmonal lession
Subpulmonal lession
Bulging diafragma
Bulging diafragma
USG ABDOMEN
 KESAN
Hepatomegali dengan multiple nodul solid
di kedua lobus cenderung metastasis.
Nodul hipoekoik di lobus kiri hepar DD/
nodul metastasis, kista
Suspek contracted gall bladder
Asites
Kalsifikasi Prostat
Abnormal Data

Physical
Examination
History 7. Icteric sclera
Taking 8.Jaundice
9.Shifting dullness
1. Abdominal 10. Chest Pain
Pain (lower right)
2. Dyspneu 11. Defans
3. Weak muscular
4. Nausea 12.Oedem lower
5. Vomiting extremity
6. Black 13. Peristaltic
defecate sound (-)
Abnormal Data
X-Foto Thoraks:

15. Diafragma kanan letak tinggi

DD/ Hepatomegali
Subpulmonal fluid collection
Subphrenic lession

Opasitas bulging di lapangan bawah hemithoraks kanan

DD/ Masa paru
Subpulmonal lesion
Bulging diafragma

USG Abdomen
16. Hepatomegali dengan multiple nodul solid di kedua lobus
cenderung metastasis.
17. Nodul hipoekoik di lobus kiri hepar
18.Asites

ECG :
19. Sinus takikardi with anterior ischemic
Abnormal Data

Laboratory finding Result

20. Anemia
Hb 12,3 g/dl
Ureum 55 mg/dL 21. Uremia
Creatinin darah 1,39 mg/dL 22.Transaminase Liver Increase
SGOT 499 mg/dL
SGPT 75 mg/dL 23. Hipoalbuminemia
Albumin 2,44 g/dL
Natrium 133,1 mmol/L 24. Hiponatremia
Kalium 5,2 mmol/L 25. Hiperkalemia
 PROBLEMLIST
PROBLEM LIST

1. Hepatoma
1. Hepatoma
2. Lung Carcinoma
2. Lung Carcinoma
3. Peritonitis Generalisata
3. Peritonitis Generalisata
4. Ascites
4. Ascites
5. Dispepsia
5. Dispepsia
6. Anemia
6. Anemia
7. Hipoalbuminemia
7. Hipoalbuminemia
8. Ischemic Heart Disease
8. Ischemic Heart Disease
9. Hiponatremia
9. Hiponatremia
10. Hiperkalemia
10. Hiperkalemia
11. Uremia
11. Uremia
1. Hepatoma
Ass: Sirosis Hati

IP Dx : Alfa- Fetoprotein, CT-SCAN, MRI,

IP Tx :

Non Pharmacology

Inf RL 20 tpm

O2 2-4L Pharmacology

Bed Rest As.Mefenamat 500 mg 3x1

Ip. Mx : Vital sign, KU,

Ip. EX :
Bed Rest / Restriction of physical activity
 Peritonitis
Ass : Lokalisata
Generalisata

IP Dx : BNO 2 Posisi

IP Tx :
Non Pharmacology

Low Fat Intake High Fiber diet

Low Sugar Intake
Ip. Mx : Vital sign, KU, Darah rutin.

Ip. EX :
Bed Rest / Restriction of physical activity
Assesment
3. DISPEPSIA
Dispepsia organik
Dispepsia fungsional :
Initial Plan of Diagnosis:
Endoscopy, UBT
Initial Plan of Therapy
1. Lansoprasol 30 mg 2x1
2. Klaritromisin 500 mg 2x1
3. Amoxicilin 1 g 2x1
Initial Plan of Monitoring
Sign and Symptom, Vital sign, KU
Initial Plan of Education
Makan teratur, istirahat cukup, tidak makan-makanan pedas/asam, kurangi stress, minum obat
 4. HYPERTENSION
Ass : -
IP Dx : Blood Pressure
IP Tx : Valsartan 80 mg 1 x 1
Captopril 12,5 mg 2 x 1
IP Mx : Blood Pressure, Organ target
damage
IP Ex : Reducing eat food tht containing salt
Reducing stress
Reducing hard activity
 5. ASCITES
Ass etiologi : Peritonitis
IP Dx : Foto abdomen, USG, CT-Scan
IP Tx :
Inj Furosemide 2 x 1 A
IP Mx : USG & Foto abdomen
IP Ex : - Reducing eat & drinks that containing salt
- Bed rest
 Hipoalbumin

Ass : - penyakit hati kronis Corection albumin

(3,5-2,66) x 60X0,8

Ip Dx : Kimia darah (3,5-2,66) x60 x0,8 = 43.2 gr

This patient need albumin

Ip Tx : Farmakoterapi : albumin 25 % in 100cc x 2 kolf

albumin 25 % in 100cc = 12,5

mg
Ip Mx :
Monitoring Albumin every day

Ip Ex :
Diet high protein ( 9 white egg)
 ASCITES

Assesment
Etiologi
hipoalbumin

Initial Plan of Diagnosis:

- kimia darah
Initial Plan of Therapy
Medikamentosa :
Inj
Furosemid 2x1 A 20mg / 2ml
albumin 25 % in 100cc = 12,5 mg
Initial Plan of Monitoring:
- USG
- Lingkar perut
- Berat badan

Ip Ex :
- menjelaskan peyakitnya pada pasien
- Menjelaskan mengenai konsumsi tinggi protein
 ANEMIA

Assessment :
Hipochrome micrositer (defisiensi Fe, thalasemia,
kronik dissease/ hiperchrome macrositer
Ip Dx :
MCV
MCH
MCHC
Ip Tx :
Folic acid 1x1
 Ip Mx:
Hb level
Anemia signs
Ip Ex
Eat high Fe food
 hiperkalemia
Ass :
Henti jantung

Initial plan Dx :
-
Initial Plan Tx :

Initial Plan Mx :
Monitoring Chemical Blood Test
Initial Plan Ex :
diuretik drugs
Furosemid 40 mg 1x1
TERIMAKASIH