CASE BASED DISCUSSION

Submitted for
A Partial Fulfillment of the Clinic Rotation Assignment in Internal Medicine Department
At Sultan Agung Islamic Hospital Semarang

by: Kiki Bangun Wijaya

30101700088

Supervisor:

dr. Nur Anna Chalimah Sa’dyah, Sp.PD, KEMD, FINASIM

DEPARTMENT OF INTERNAL MEDICINE

FACULTY OF MEDICINE SULTAN AGUNG ISLAMIC UNIVERSITY
SEMARANG
2022
 CASE REPORT

I. PATIENT’S IDENTITY
Name : Mr. S
Age : 68 years old
Gender : male
Religion : Islam
Address : Rusunawa karangroto baru Blok B
Occupation : retired
Room : Endocrine Clinic
Medical Record : 01 10 xx xx
Date of Entry : Oct 13th 2022
II. HISTORY TAKING
Main Complaint: Shortness of breath

History of Current Illness:

The patient came to the Sultan Agung Hospital for a check-up with shortness-of-breath,
the patient has had complaints since the last 2 years, complaints of shortness of breath
appear when the patient does activities such as walking for a few minutes and going up
and down stairs, shortness of breath improves when resting. The patient is currently not
working, but previously worked in furniture, ceramics and construction workers which
exposed the patient to a lot of dust. The patient also has a history of smoking since the
age of 15 years and consumes 1 pack a day. Patients also often use mosquito coils when
going to sleep. Another complaint experienced by the patient is that the shortness of
breath is sometimes accompanied by a wheezing sound, dry cough (2 weeks ago it was
more severe) and heaviness in the chest.

History of Previous Illness

• Similar symptom/illness (-)
• Hypertension history (-)
• DM history (-)
• Asthma history (-)
• Allergy history (-)
• Cardiac Disease (-)
• Drug allergy (-)

Family’s history of disease

• Hypertension history (-)
• DM history (-)
• Asthma and allergy history (-)

Social-Economic History
 Hospital cost certified by BPJS
  Patient live with his wife and 2 children
 Minimal ventilation in his house
 Using mosquito coils when sleeping
 Patient works at ceramic factory before retire

III. GENERAL PHYSICAL EXAMINATION

DATE : August 10th, 2022
 Awareness : composmentis
 Vital sign
BP : 135/75 mmHg
Pulse : 80 x/minute
Temperature : 36,5 oC
RR : 35x/minute

 BMI
Weight : 55 kg
High : 150 cm
BMI : 24,4 kg/m2 (Overweight)

◦ Skin : itching (-), jaundice (-), pale (-).

◦ Head : headache (-)

◦ Eyes : blurred vision (-), Conjunctival anemic (-/-), Conjunctival Icterus (-/-)

◦ Ears : hearing loss (-), discharge (-)

◦ Nose : nosebleed (-), discharge (-)

◦ Mouth : cyanosis (-), thrush (-)

◦ Throat : pain swallow (-), hoarseness (-), difficult in swallowing (-)

◦ Neck : trachea deviation (-), lymph hypertrophy (-), JVP (N)

◦ Chest : Blood (-), sikatrik (-), striae (-)

 ◦ Chest : cough (-), blood (-)

◦ Cardiac : chest pain (-), palpitations (-)

◦ Disgestive : abdominal pain (+), nausea vomiting (-), cicatrix (-)

◦ Musculosceletal : weak (-), rigid (-), back pain (-), edema (-), crepitations (-)

Interpretation : Normal

IV. CHEST EXAMINATION – LUNG

EXAMINATION ANTERIOR POSTERIOR

Inspection – RR : 35x/min RR : 35x/min

Static Hyperpigmentation (-) Hyperpigmentation (-)
Spider nevi (-) Spider nevi (-)
Atrophy M. Pectoralis (-) Atrophy M. Pectoralis
Hemithorax D=S (-)
ICS Normal Hemithorax D=S
Diameter AP : 25 cm LL : 38 ICS Normal
cm Diameter AP : 25 cm LL
: 38 cm

Inspection – Up and down of hemithorax Up and down of

Dynamic D=S hemithorax D=S
Muscle retraction of breathing Muscle retraction of
(+) breathing (+)
Retraction ICS (-) Retraction ICS (-)

Palpation Tenderness (-), Mass (-) Tenderness (-), Mass (-)

tactile fremitus (N) tactile fremitus (N)

Percussion Sonor (+) Sonor (+)

Auscultation Vesicular (+), Ronchi (-), Vesicular(+), Ronchi (-),
Wheezing (-) Wheezing (-)
 Interpretation : Normal

V. THORAX – COR EXAMINATION

INSPECTION Ictus cordis isn’t seen.

PALPATION Palpable (-), pulsus parasternal (-), sternal lift (-), pulsus
epigastrium (-)

PERCUSSION  Upper borderline of heart : ICS II left sternal line

 Waist of heart : ICS III left parasternal line
 Lower right borderline of heart : SIC V linea sternalis
dextra
 Lower left borderline of heart : SIC V, linea axilaris
anterior

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 (-)

Interpretation : Cardiomegaly
VI. ABDOMINAL EXAMINATION

EXAMINATION RESULTS
Inspection Symmetrical, cicatrix (-), Striae (-), Vein’s
enlargement (-), Caput medusa (-), Spider nevi
(-), edema (-)
Auscultation Peristaltic (+), Abdominal aorta’s bruits (-),
Splenic Artery, Femoral Artery (-)
Percussion Tympanic, Shifting dullness (-) Undulation test
(-), Liver dullness (-), Liver span (-), Traube’s
space (tympanic)
Palpation Mass (-), Pain (-), Hepatomegaly (-), Liver,
Kidney & Spleen are normal, Splenomegaly (-)
Murphy’s sign (-)

Interpretation : NORMAL

VII. EXTREMITIES
SUPERIOR INFERIOR
Edema -/- -/-
Cold -/- -/-
Heat -/- -/-
Fluctuation -/- -/-
Pain -/- -/-
 Numbness -/- -/-
Absces -/- -/-
Capillary refille <2s <2s

Interpretation : Normal

VIII. ADDITIONAL EXAMINATION

X-PHOTO THORAX
Interpretation :
Cor: Laterocaudal shift apex
Aortic elongation with aortic arch calcification
Pulmo: rough bronchovascular pattern
Right and left hilar thickening
Right hemidiaphragm at the level of ribs 8-9 posterior
Right and left constophrenic sinus is good
There is clipping on the right posterior 8-9 ribs
Interpretation:
• Cardiomegaly (LVH)
• Aortic elongation with aortic arch cassification
• Bronchitis appearance
• Right and left hilar thickening

IX. ABNORMALITY DATA

History Taking
• Shortness of breath
• Smoking since 15 y.o
• Using mosquito coils when sleeping
Physical Examination
• Takipneu
• Diameter of Chest AP:LL = 1:1,52
• cardiomegaly
Additional Examination
X-photo Thorax :
• Cardiomegaly
• Increase of brochovascular appearance

X. PROBLEM LIST
1. COPD (chronic Obstructive Pulmonary Disease)
XI. DISCUSSION
Patient Progress 11/10/22
S:
Shortness of breath
Smoking history since 15 y.o
O:
• Takipneu
• Diameter of Chest AP:LL = 1:1,75
• Cardiomegaly
X-foto thorax :
• Cardiomegaly (LVH)
• Aortic elongation with aortic arch cassification
• Bronchitis appearance
• Right and left hilar thickening
A : COPD (Chronic Obstructive Pulmonary Disease)
P:
Salbutamol 2mg 2x1
Levofloxacin 1x500mg 7 days
Cetirizine 2x10 mg
Celexocib 1x100mg
Calcitirol 1x0.25 mg
Follow up : Spirometry

Patient Progress 13/10/22

S:
Small joint pain upper and lower extremitires
O:
• Takipneu
• Diameter of Chest AP:LL = 1:1.52
A : COPD (Chronic Obstructive Pulmonary Disease)
P:
Salbutamol 2mg 2x1
Levofloxacin 1x500mg 7 days
Cetirizine 2x10 mg
Celexocib 1x100mg
Calcitirol 1x0.25 mg

Patient Progress 18/10/22

S:
Small joint pain upper and lower extremitires
O:
• Takipneu
• Diameter of Chest AP:LL = 1:1.52
A : COPD (Chronic Obstructive Pulmonary Disease)
P:
Salbutamol 2mg 2x1
Levofloxacin 1x500mg 7 days
Cetirizine 2x10 mg
Celexocib 1x100mg
Calcitirol 1x0.25 mg
Na. Diclofenac 1x25mg

Patient Progress 25/10/22

S:
Small joint pain upper and lower extremitires
Shortness of breath getting better
O:
• Takipneu
• Diameter of Chest AP:LL = 1:1.52
A : COPD (Chronic Obstructive Pulmonary Disease)
P:
Salbutamol 2mg 2x1
Levofloxacin 1x500mg 7 days
Cetirizine 2x10 mg
Celexocib 1x100mg
Calcitirol 1x0.25 mg
Na. Diclofenac 1x25mg

APPENDIX