CHAPTER I

PRELIMINARY

1.1 Background
Cardiocerebrovaskular blocks are the 10 block in the third semester of the
Curriculum Based on Medical Education Competency, Faculty of Medicine,
Palembang Muhammadiyah University. On this occasion a scenario case study
A Periculum in mora Mrs. A, a 48 years old woman, brought to the emergency
department of RSMP by her family with a chief complain of shortness of
breath that keeps on worsening since 4 hours ago. The shortness of breath
were not triggered by activity or weathers change, and were not followed with
wheezing. Mrs. A also complains of productive cough accompanied with pain
while swallowing and fever since one weeks ago, she went to the Puskesmas
and was given an antibiotic but she didnt take it. Her blood sugar level also
being checked at the Puskesmas, and the result was 280 mg/dl, and she also
claimed that she often feels thirsty, famished, and urinate a lot, then she was
given an oral anti diabetic but she didnt take it regularly.
According to her family, Mrs. A had a medical history of Diabetes Mellitus
since the age of forty, but she didnt take her medicine regularly, and seldomly
control her condition to the Puskesmas.
Physical Examination :
General Appearance: Looks severely sick, apathic, BH: 154 cm, BW 40 kg
Vital Sign : BP 100/60 mmHg, HR 120x/mnt, Temp 38,8°C, RR: 38x/menit
(deep and fast breathing)
Head : Pale conjungtive (-/-), icteric sclera (-/-)
Neck : JVP 5-2 cmH2O
Thorax : Heart and lung within normal limits
Abdoment : flat, supple, bowel movement (+), hepar and lien were not
palpable
Extremities : cold extremities (-), edema (-/-). Turgor return slowly.

1
 Laboratory Examination:
Blood Chemistry: Hb 13g/dl, Leukocyte 18.000/mm3, thrombocyte 250.000/
mm3
BSN300 mg/dl
Urinalysis: Keton urin +3, glukose urin +3

1.2 Purpose and objectives

The intent and purpose of this case study tutorial report, namely:
1. As a tutorial group assignment report which is part of the KBK learning
system at the Faculty of Medicine in Muhammadiyah University
Palembang.
2. Can resolve the case given in the scenario with the group discussion
learning analysis method.
3. The achievement of the objectives of the tutorial learning method.

2
 CHAPTER II
DISCUSSION

2.1 Tutorial Date

Tutor : dr. Ratih Pratiwi, SpOG.
Moderator : Putra Pratma Adi Candra
Desk secretary : Aninda Afrilia Aryani
Board secretary : Syabrina Afni Mahmuda
Time : Tuesday, December 24th 2019 ( 1st stage tutorial)
13.00 – 15.00
Thursday, December 26th 2019 (2nd Stage Tutorial)
13.00 – 15.00

2.2 Rules
1. Switch the phone off or in silent
2. Hold hand when asking question and arguments
3. Ask for permission in advance when going out of the room
4. Each tutor member is expected to wear marker

3
2.3 Scenario
“Periculum in mora”
Mrs. A, a 48 years old woman, brought to the emergency department of
RSMP by her family with a chief complain of shortness of breath that keeps
on worsening since 4 hours ago. The shortness of breath were not triggered by
activity or weathers change, and were not followed with wheezing. Mrs. A
also complains of productive cough accompanied with pain while swallowing
and fever since one weeks ago, she went to the Puskesmas and was given an
antibiotic but she didnt take it. Her blood sugar level also being checked at the
Puskesmas, and the result was 280 mg/dl, and she also claimed that she often
feels thirsty, famished, and urinate a lot, then she was given an oral anti
diabetic but she didnt take it regularly.
According to her family, Mrs. A had a medical history of Diabetes Mellitus
since the age of forty, but she didnt take her medicine regularly, and seldomly
control her condition to the Puskesmas.
Physical Examination :
General Appearance: Looks severely sick, apathic, BH: 154 cm, BW 40 kg
Vital Sign : BP 100/60 mmHg, HR 120x/mnt, Temp 38,8°C, RR: 38x/menit
(deep and fast breathing)
Head : Pale conjungtive (-/-), icteric sclera (-/-)
Neck : JVP 5-2 cmH2O
Thorax : Heart and lung within normal limits
Abdoment : flat, supple, bowel movement (+), hepar and lien were not
palpable
Extremities : cold extremities (-), edema (-/-). Turgor return slowly.

Laboratory Examination:
Blood Chemistry: Hb 13g/dl, Leukocyte 18.000/mm3, thrombocyte 250.000/
mm3
BSN300 mg/dl
Urinalysis: Keton urin +3, glukose urin +3

4
2.4 Clarification of Term
1. Apathic Is a condition where someone does not care
or feel shy about the surrounding
environment.
2. Diabetes melitus Any abnormality characterized by excessive
urinary excretion due to impaired function
of the hormone insulin.
3. Pale conjuntive Pale on the smooth membrane lining the
eyelid.
4. Turgor Tissue tension caused by many blood filled.
5. Shortness of breath Respiratory disorders caused by
interference with the respiratory tract and
lack of Hb levels in blood cells.
6. Cough Cough is a natura response from the body as
a defense system to remove substance and
particles from respiratory tract.
7. Blood sugar Is (Glucose in the blood) the end product of
carbohydrate metabolism and the main
energy source whose use is controlled by
insulin.
8. Keton urine Excessive ketone in the urine (ketones:
several groups of organic compounds
containing carbonyl groups whose carbon
atoms bind to 2 other carbon atoms.
9. Icteric sclera Yellowish color in the sclera due to
hyperbillirubinemia and pigment
deposition.
10 Hemoglobin Is protein that is in red blood cells.
.
11 Leukocyte White blood cell; colorless blood cells that
. are able to move ameboidically, with their
main function being to protect the body
against microorganisms that cause disease.
12 Edema Abnormal accumulation of fluid outside and

5
 . inside cells.
13 Thombocyte Is blood cells which are important in normal
. blood clotting.
14 Vital signicteric sclera Yellowish color in the sclera due to
. hyperbillirubinemia and pigment depositio.

2.5 Identification of Problem

1. Mrs. A, a 48 years old woman, brought to the emergency department of
RSMP by her family with a chief complain of shortness of breath that
keeps on worsening since 4 hours ago. The shortness of breath were not
triggered by activity or weathers change, and were not followed with
wheezing.
2. Mrs. A also complains of productive cough accompanied with pain while
swallowing and fever since one weeks ago, she went to the Puskesmas and
was given an antibiotic but she didnt take it.
3. Her blood sugar level also being checked at the Puskesmas, and the result
was 280 mg/dl, and she also claimed that she often feels thirsty, famished,
and urinate a lot, then she was given an oral anti diabetic but she didnt take
it regularly.
4. According to her family, Mrs. A had a medical history of Diabetes
Mellitus since the age of forty, but she didnt take her medicine regularly,
and seldomly control her condition to the Puskesmas.
5. General Appearance: Looks severely sick, apathic, BH: 154 cm, BW 40 kg
Vital Sign : BP 100/60 mmHg, HR 120x/mnt, Temp 38,8°C, RR:
38x/menit (deep and fast breathing)
Head : Pale conjungtive (-/-), icteric sclera (-/-)
Neck : JVP 5-2 cmH2O
Thorax : Heart and lung within normal limits
Abdoment : flat, supple, bowel movement (+), hepar and lien were not
palpable
Extremities : cold extremities (-), edema (-/-). Turgor return slowly.

6
 6. Laboratory Examination:
Blood Chemistry: Hb 13g/dl, Leukocyte 18.000/mm3, thrombocyte
250.000/ mm3
BSN 300 mg/dl
Urinalysis: Keton urin +3, glukose urin +3

2.6 Priority of Problem

No. 1
Mrs. A, a 48 years old woman, brought to the emergency department of
RSMP by her family with a chief complain of shortness of breath that keeps
on worsening since 4 hours ago. The shortness of breath were not triggered by
activity or weathers change, and were not followed with wheezing.
Because can increase mortility and morbility if we didnt take care of that.

2.7 Analysis of Problem

1. Mrs. A, a 48 years old woman, brought to the emergency department of
RSMP by her family with a chief complain of shortness of breath that
keeps on worsening since 4 hours ago. The shortness of breath were not
triggered by activity or weathers change, and were not followed with
wheezing.
a. What is the anatomy and phisiology in the case ?
b. What is the meaning of the head complaining of shortness of breath
that has continued to deteriorate since 4 hours ago?
Jawab : Shortness of breath is an indication that there may have
been respiratory or vascular disorders in distributing O2 in the body.
Shortness of breath is one form of emergency because it involves vital
signs so that if the shortness of breath experienced is getting heavier as
in the case of shortness of breath heavier since 4 hours ago shows that
the body has compensated to meet the needs of O2 in the body and
shortness of breath increasingly great because it's not immediately
managed quickly and precisely. (Price, Sylvia A., 2006)

7
 c. What is the relation between sex and age in the case?
Jawab :
a. Age: Can occur at any age.
As we get older our body functions decline and are prone to degenerative
diseases.
b.Gender: Men and women have the same ratio
d. What is the etiology of shortness of breath in the case?
e. How is the mechanism of shortness od breath in the case?
f. What is the meaning The shortness of breath were not triggered by
activity or weathers change, and were not followed with wheezing?
Jawab :
The meaning of shortness of breath is not influenced by the weather,
activity and were not followed with wheezing is the occurrence of shortness of
breath occurs not as a result of external stressors, thus getting rid of the possibility
of cardiovascular disorders and respiration, because in cardiovascular disease
shortness of breath can occur and get worse in moderate to severe physical
activity. In some diseases due to respiratory system disorders, for example asthma
that tends to cool weather is one of the triggers of shortness of breath.
(Price&Wilson. 2013)

g. What is possibility disease with shortness breath?

Jawab :
 Heart: Congestive heart failure, coronary artery disease, arthmia,
Perditis
 Pulmo: Chronically obstructive pulmonary disease, asthma,
pneumonia, gastroesophageal reflux disease with respiration
 Pyschogenic: Panic attacks, restlessness, hyperventilation
 Endocrine: metabolic acidosis, medications – drugs
(Rasmin et al,2016)

8
 - Asthma
- Pneumonia
- Congestive heart failure
- Pulmonary embolism
- Pulmonary core
- Pleural effusion
- Trauma
- Neurologic disease
- Chronic bronchitis
(Setiati, dkk. 2017)

2. Mrs. A also complains of productive cough accompanied with pain while

swallowing and fever since one weeks ago, she went to the Puskesmas and
was given an antibiotic but she didnt take it.
a. What is the meaning of Mrs. A also complains of productive cough
accompanied with pain while swallowing and fever since one weeks
ago, she went to the Puskesmas and was given an antibiotic but she
didnt take it?
Jawab :
The meaning is probably a sign of an inflammatory process due
to infection. The meaning of treatment to the health center and given
antibiotic drugs but do not take it regularly, meaning that he does not
obey the rules of taking the drug, which causes the drug does not have
an optimal effect.
Its meaning mrs. A has an UPRI where the clinical manifestations
include coughing, fever, difficulty swallowing, etc. UPRI can also be a
trigger for the occurrence of diabetic ketoacidosis.
Makna itu mungkin merupakan tanda dari proses inflamasi karena
infeksi. Arti pengobatan ke puskesmas dan diberikan obat antibiotik
tetapi jangan diminum secara teratur, artinya dia tidak mematuhi

9
 aturan minum obat, yang menyebabkan obat tidak memiliki efek
optimal.
Artinya mrs. A memiliki ISPA di mana manifestasi klinisnya termasuk
batuk, demam, kesulitan menelan, dll. ISPA juga bisa menjadi pemicu
terjadinya ketoasidosis diabetikum.
b. What is the possibility of antibiotics being given?
Jawab :
1. Sulfonylureas (eg, glipizide, gliburid) use their primary effects to
stimulate the release of endogenous insulin
2. Metformin (a biguanid) suppresses the release of liver glucose and
increases the release of liver glucose and increases insulin
sensitivity
3. Tiazolidinediones (for example, rosiglitazon, pioglitazon) as well
as in dividing the capacity of metformin to reduce insulin
resistance, reduce glucose and insulin levels with a small risk of
hypoglycemia
2. Akarbosa delays the absorption of carbohydrates consumed,
thereby decreasing postprandial glucose levels in these patients.
(Price & Wilson, 2013)

c. What is etiology productive cough accompained with pain while

swallowing and fever?
d. What is the pathophisiologi productive cough accompained with pain
while swallowing and fever?
e. What the relationship between short breathing with productive cough,
fever, and pain while swalowwing?
f. What impact is given antibiotics but not regularly?

3. Her blood sugar level also being checked at the Puskesmas, and the result
was 280 mg/dl, and she also claimed that she often feels thirsty, famished,
and urinate a lot, then she was given an oral anti diabetic but she didnt take

10
 it regularly.
a. What is the meaning Her blood sugar level also being checked at the
Puskesmas, and the result was 280 mg/dl?
Jawab : The meaning is experiencing Diabetes Mellitus in which the
diagnosis of DM can be established if it meets one of the criteria,
namely if clinical symptoms are found polyuria, polydipsia,
polyphagia, decreased body weight, and blood glucose levels when
more than 280 mg / dl; or if it is asymptomatic, then the blood glucose
level should be over 280 mg / dl or fasting blood sugar levels higher
than normal or with a glucose tolerance test of fasting blood glucose
levels> 140 mg / dl. (Price A, Wilson, 2013)

b. What is the meaning of she also claimed that she often feels thirsty,
famished, and urinate a lot?
c. What is the meaning she was given an oral anti diabetic but she didnt
take it regularly ?
d. What is the relationship of the main conplaint with additional
complaints?
e. What is impact is she was given an oral anti diabetic but she did not
take it regularly?
Jawab :
Disobedience increases the risk of complications and worsens the
illness.(Pratita,ND. 2012)
Can cause complications in the form of: heart attack, kidney failure,
stroke, gamgren dam and death (Price & Wilson, 2013)

f. What is the etiology of the case (feels thirstym famished and urinate a
lot)?
g. What is the pathopyshiology of the additional complaints?

4. According to her family, Mrs. A had a medical history of Diabetes

11
Mellitus since the age of forty, but she didnt take her medicine regularly,
and seldomly control her condition to the Puskesmas.
a. what does it mean According to his family, Mrs. A has a medical
history of Diabetes Mellitus since the age of forty, but he does not take
medication regularly, and rarely controls his condition to the
Puskesmas?
Jawab :
The meaning is a history of DM disease experienced by mrs. A
this has been a long time and become out of control due to mrs. A does
not regularly take medication and rarely check up his condition at the
health center

b. What is impact she didnt take her medicine regularly, and seldomly
control her condition to the Puskesmas?
c. What is classification of diabetes melitus?
Jawab :

1. Diabetes Mellitus
a) Diabetes mellitus type 1
Because it is autoimmune, due to autoimmune dysfunction with
damage to beta cells.
b) Type 2 diabetes mellitus
Type 2 diabetes mellitus was once known as the adult type or the
non-dependent insulin type. Obesity is often associated with
diseases of this type.

2. Gestational Diabetes (GDM)

Gestational diabetes or gestational diabetes mellitus. Risk factors for
GDM are old age, ethnicity, obesity, multiparity, family history, and
a history of previous gestational diabetes. Because there is an
increase in the secretion of various hormones that have a metabolic

12
 effect on glucose tolerance, pregnancy is a diabetogenic condition.

3. Other special types, are:

- Genetic abnormalities are well recognized in four different forms of
mutations and phenotypes (MODY 1, MODY 2, MODY 3, MODY
4).
- Diseases of the pancreatic exocrine cause chronic pancreatitis.
- Endocrine diseases such as Cushing's syndrome and acromegaly.
- Medications that are toxic to beta cells.
- infection.
 (Abbas and Kumar, 2015)
d. What is the etiology of diabetes milletus?
e. What are the anti-diabetic drugs and preparations?
f. What is the risk factor of diabetes melitus?
Jawab :
1. Obesity (overweight)
There is a significant correlation between obesity and blood
glucose levels, at the level of obesity with BMI> 23 can cause an
increase in blood glucose levels to 200mg%.
Hypertension
2. Increased blood pressure in hypertension is closely related to
improper storage of salt and water, or increased pressure from the
body in peripheral blood vessel circulation.
3. Family history of diabetes mellitus
A person suffering from Diabetes Mellitus is suspected of having a
diabetes gene. It is suspected that diabetes talent is a recessive
gene. Only people who are homozygous with the recessive gene
suffer from Diabetes Mellitus.
4. Dyslipedemia
Is a condition characterized by an increase in blood lipid levels
(triglycerides> 250 mg / dl). There is a relationship between an

13
 increase in plasma insulin and a low HDL (<35 mg / dl) often
found in diabetic patients.
5. Age
Based on research, the most age affected by Diabetes Mellitus is>
45 years.
6. Birth history
A history of recurrent abortion, giving birth to a deformed baby or
a baby weighing> 4000gram
7. Genetic Factors
Type 2 DM originates from genetic interactions and various mental
factors. This disease has long been thought to be related to familial
aggregation. The risk of anemia in the case of type 2 diabetes will
increase two to six times if the parents or siblings experience this
disease.
8. Alcohol and Cigarettes
Changes in lifestyle are associated with an increase in the
frequency of type 2 diabetes. Although most of these increases are
associated with an increase in obesity and a reduction in physical
inactivity, other factors are related to changes from the traditional
environment of westernized environment which include changes in
consumption alcohol and cigarettes, also play a role in increasing
DM type 2. Alcohol will disrupt blood sugar metabolism,
especially in people with DM, which will complicate blood sugar
regulation and increase blood pressure. A person will increase
blood pressure if consuming ethyl alcohol more than 60 ml / day
which is equivalent to 100 ml proof whiskey, 240 ml wine or 720
ml. Risk factors for non-communicable diseases, including Type 2
diabetes, can be divided into two. The first is risk factors that
cannot change, such as age, genetic factors, unbalanced diet, sex,
marital status, education level, occupation, physical activity,
smoking habits, alcohol consumption, body mass index. (Hastuti

14
 Rini, 2008)
g. What is the pathophysiology of Diabetes Mellitus?

5. General Appearance: Looks severely sick, apathic, BH: 154 cm, BW 40 kg

Vital Sign : BP 100/60 mmHg, HR 120x/mnt, Temp 38,8°C, RR:
38x/menit (deep and fast breathing)
Head : Pale conjungtive (-/-), icteric sclera (-/-)
Neck : JVP 5-2 cmH2O
Thorax : Heart and lung within normal limits
Abdoment : flat, supple, bowel movement (+), hepar and lien were not
palpable
Extremities : cold extremities (-), edema (-/-). Turgor return slowly.
a. How is the interpretation of Physical Examination?
b. How is the abnormal mechanism of Physical Examination?

6. Laboratory Examination:
Blood Chemistry: Hb 13g/dl, Leukocyte 18.000/mm3, thrombocyte
250.000/ mm3
BSN 300 mg/dl
Urinalysis: Keton urin +3, glukose urin +3
a. How is the interpretation of Laboratory Examination?
b. How is the abnormal mechanism of Laboratory Examination ?

7. How to diagnose?
8. What is the differential diagnose?
9. What is the additional examination?
10. What is a working diagnose?
a. Definition
b. Clinical manifestations
c. Epidemiology
d. Pathophysiology

15
 e. Risk Factors
f. Etiology
11. How to treatment for this case?
12. What is the complication in the case?
13. What is the prognose in the case ?
14. What is the SKDU in the case?
15. What is the islamic view in the case?
Jawab :

"Whatever blessings you get are from Allah and what disasters that befall
you, then from (your mistakes) yourself". (QS.An Nissa (4): 79).

Indeed, Allah lowers sickness and medicine, and he has decreed for every
cure, so do not cure with the unclean thing. " (Narrated by Abu Dawood,
3372) .

2.8 Hypothesis
Mrs. A, a 48 years old woman, brought to the emergency department of
RSMP by her family with a chief complain of shortness of breath that keeps
on worsening ecketoasidosis + DM tipe 2 not control her condition.

2.9 Conceptual Framework

16
 Risk factor
(Age, gender, history family)

DM tipe 2
(take medicine Irregular)

Increase level up acid in the

blood

ketoasidosis

Fever Shortnes of breath Pain Swallowing Cough

17