CBD

CASE BASE DISCUSSION

FATIYA HIDAYATI
30101306943

ADVISOR : DR. H. M. SAUGI ABDUH, SP.PD., KKV, FINASIM

 PATIENT’S IDENTITY
Name : Mrs. Y
Age : 57 y.o.
Gender : Feale
Religion : Moslem
Address : Jl. Petek Kp 03/06 Dadapsari Semarang
MR number : 01334188
Room : Baitul Izzah 2 – Q
Entry date : November 14st, 2017
Date out : November 20st, 2017
 HISTORY TAKING
Main Problem
• Dyspneu
History of Present Illness
• Patient came into the emergency department in
Islamic Hospital of Sultan Agung Semarang,
complained about his abnormal breathing
(dyspneu). Its started one week ago. At that day, the
dyspneu often come and worsening when do an
activity. Patient felt better when she took a rest and
sit down. Patient also complained cough with
sputum ± 2 mounth, epigastric pain, nausea,
vomitus.
 HISTORY OF
HISTORY OF PREVIOUS FAMILY’S HISTORY OF SOSIO-ECONOMIC
ILLNESS DISEASE HISTORY :

• Hypertension history • Hypertension history (-) • Hospital cost

(-) • DM history (-) certified by
• DM history (-) • Asthma history (-) • “JKN NON PBI ”
• Asthma history (-)
• Alergy history (-)
• Smoking (-)
• Tuberculosis (+)
 SISTEMIC ANAMNESIS
Chief Complains : Abnormal breathing (Dyspneu)
Onset : 1 week ago
Location : Chest
Chronology : Patient felt dyspneu for a long time, he has history of
tuberculosis, patient ever care in hospital twice, with the same complains, the first time
patient diagnosed for tuberculosis at Desember 2016, have treatment OAT for 2 mounth but
patient discontinued treatment. For one week ago, patient feel dyspneu again and at that
day, the dyspneu often come and worsening when do an activity
Quality and Quantity : The worsening when do activity. The dyspneu attack come
more than one time, each attack worsening and longer
Modification factor : Better when he took a rest and sit down.
Comorbid complains: Cough, Epigastric pain, nausea, vomitus.
16/11/2017 X FOTO THORAX
Foto Dati Bkpm Semarang 25 Juli 2017
COR : CTR <50%
PULMO :
Corakan bronkovascular meningkat
Tampak bercak pada lapangan atas paru kiri.

Tampak kavitas disertai bercak sekitarnya

pada lapangan bawah paru kiri.
Diafragma dan sinus kortofrenikus kanan
baik, kiri suram.

KESAN :
COR : TAK MEMBESAR
PULMO : TB PARU
EFUSI PLEURA KIRI
 PHYSICAL EXAMINATION
General : weakness
15/11/2017

Awareness : compos mentis (GCS 15)

Antropometri Status
Height = 158 cm, Weight = 50 kg
BMI = BB(kg)/TB²(m²)
= 50 kg/(1,55 m)²
= 20,08

Vital Sign
Blood Pressure : 130/80 mmHg RR : 36x/menit
Heart Rate : 108x/menit Temp : 36,7

Intepretation : Tachycardi, Tachypneu

 PHYSICAL EXAMINATION
Skin : itching (-), jaundice (-), pale (-)

Head : headache (-)

Eyes : blurred vision (-), red eyes (-), jaundice sclera (-/-)

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

Nose : nosebleed (-), discharge (-)

Mouth : cyanosis (-), thrush (-)

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

Neck : trachea deviation (-), lymph hypertrophy (-)

Chest : dyspnea (+), cough (+), sputum (+), blood (-)

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

Digestive : epigastric pain (+), nausea (+), vomitus (+)

Muscular : weak (-), rigid (-), back pain (-)

Extremity : edema extremity (-)

Intepretation : Dyspnea, Cough, Sputum, Epigastric Pain, Nausea, Vomitus

 LUNG EXAMINATION
INSPECTION ANTERIOR POSTERIOR

Static RR : 36x/min, Hyperpigment (-), spider RR : 36x/min, Hyperpigment (-), spider

nevi (-), atrophy Pectoral Muscle (-),
Hemithoraks D=S, ICS Normal, D.AP < LL
Dynamic Up and down of hemitoraks D=S,
abdominothorakal breathing, (-), muscle
retraction of breathing (-),
retraction ICS (-)
Palpation Palpable pain(-), tumor (-), Stem fremitus
(increase)
Percution redup
nevi (-), Hemithoraks D=S,
ICS Normal, Diameter AP < LL
Up and down of hemitoraks D=S,
abdominothorakal breathing (-), muscle
retraction of breathing(-),
retraction ICS (-)
Palpable pain (-), tumor (-), Stem
fremitus (increase)
redup

Auscultation Vesicular decrease, Vesicular decrease

Intepretation : Tachypneu, Stem Fremitus increase, redup,Vesicular decrease

 CARDIAC EXAMINATION
Inspection : Ictus cordis isn’t seen.
Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-), sternal lift (-).
Percussion : dull sound
 Upper borderline of heart : ICS II left sternal line
 Waist of heart : ICS III left parastern line
 Lower right borderline of heart : ICS V right sternal line
 Lower left borderline of heart : ICS V, 2 cm lateral from left mid clavicle line

Intepretation : NORMAL
 CARDIAC EXAMINATION
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 (-)

Intepretation : NORMAL
 ABDOMEN EXAMINATION
Inspection : symetric, sycatric (-), striae(-), enlargement of vena (-), caput medusa (-).
Auscultation : peristaltic (+)
Palpation :
• Superfisial : tight (-), mass (-), epigastrial pain (+)
• Deep : Abdominal pain (-), liver, kidney, and spleen weren’t palpable, Murphy’s sign (-)
Percussion : tympani, side of deaf (-), shifting dullness (-)
• Liver : deaf(+), right liver span 11 cm, left liver span 6 cm
• Spleen : Throbe space percussion (+)  tympani

Intepretation : Epigastric pain

 EXTREMITY EXAMINATION

Ektremitas Superior Inferior

Oedeme -/- -/-

Cold -/- -/-

Jaundice -/- -/-
Intepretation : Normal
 LAB EXAMINATION
14/11/2017
Examination Result Normal Examination Result Normal

HEMATOLOGI KIMIA

Hemoglobin 13,3 11,7-15,5 Na, K, Cl

Natrium 131,7 135-147

Hematokrit 38,3 33-45

Leukosit 14,74 3,6-11 Kalium 12,8 3,5-5

Trombosit 367 150-440 Chloride 105,8 95-105

Gol.Intepretation
Darah/ :O/+
Leukositosis, Hiperglikemi, Hiperkalemi, Hiperchloremia,
IMUNOSEROLOGI
Rh
HBsAg Kualitatif Non Non
 LAB EXAMINATION
15/11/2017
Examination Result Normal Examination Result Normal

Ureum 23 10-50 Bilirubin total 1,1 0,1-1,0

Creatinin 0,87 0,6-1,1

Bilirubin direk 0,6 0-0,2

SGOT 13 0-35
Bilirubin indirek 0,55 0-0,75
SGPT 9 0-35

Na, K, Cl

Natrium 129,5 135-147

Intepretation : Hiponatremia,Hipokalemi, Hiperbilirubinemia
Tanggal LAB EXAMINATION
Pemeriksaan Hasil Nilai (BTA)
Keterangan
Rujukan
16/11/201 P. BTA (Sputum) Sewaktu I Negatif
7 BTA :3+
Lekosit : > 25/LP
Epitel : 1-2/LP
21/11/201 P. BTA (Sputum) Pagi Negatif
7 BTA :3+
Lekosit : > 25/LP
Epitel : 1-2/LP
Intepretation : BTA 3+
Negatif : Tidak ditemukan
BTA dalam 100 lapang
pandang.
Scanty : Ditemukan 1-9 BTA
dalam 100 lapang pandang
1+ : 10-99 BTA dalam 100
lapang pandang
2+ : 1-10 BTA dalam 100
lapang pandang
3+ : >10 BTA setiap lapang
pandang
 ECG
14/11/2017
 INTERPRETASI ECG
14/11/2017

IRAMA : Sinus rhytm

REGULARITAS : Regular
FREKUENSI : 1500/10 kotak kecil = 150 kali per menit ( Takikardi)
AXIS : L1 (+) AVF (+)  NAD
GELOMBANG P : 2 x 0,04 = 0,08 s
PR INTERVAL : 3 x 0,04 = 0,12 s
GELOMBANG Q : Normal
QRS COMPLEX : 0,08 s
ST SEGMEN : ST depresi di lead II, III, aVF
GELOMBANG T : T prekordial : <10 mV T ekstremitas : <5 mV
ZONA TRANSISI : Tidak dapat dinilai
INTERPRETASI : SINUS TAKIKARDI, Iskemik Inferior
 ABNORMALITAS
Physical DATA Laboratory
Examination
History
Taking • 7. Tachycardi
• 1. Dyspneu (HR : 150 • 14/11/2017
• 2. Cough x/minute) • 13.Leukositosis
• 3. Sputum • 8. Tachypneu • 14. Hiperglikemi
(RR : 40
• 4. Nausea • 15. Hiperkalemi
x/minute)
• 5. Vomitus • 16.
• 9. Epigastric
• 6. History Hiperchloremi
pain
of • 15/11/2017
• 10. Stem
tuberculosi fremitus • 17.Hipokalemi
s decrease • 18. Hiponatremi
• 11. Vesicular • 19.Hiperbilirube
decrease nemia
• 20. BTA : 3+
 ABNORMALITAS DATA

X-Ray ECG

• 21. TB Paru • 23. Sinus

• 22. Efusi Tachycardi
Pleura dengan
iskemik
inferior
PROBLEM LIST

1. 2. 3.
Tubercul Efusi Hiperkale 4.
osis pleura mi Dyspepsia
5. 7.
6.
Hiponatr Hiperbiliru
Hiperglik bin
emi emi
 1. TUBERCULOSIS
Ass :-
IP Dx :-
IP Tx :
Pharmacologi :
2(HRZE)S / (HRZE) / 5(HR)3E3  For This Patient Because
The Patient Is TB Lost To Follow Up)
 1. TUBERCULOSIS
IP Mx :
 Bacteriology  BTA (The End 2nd Month, 6 Month)
 Clinical Manifestation  Body Weight, Cough, Sweating In The Night
 Side Effect Of The Drugs
 Laboratoric : SGOT, SGPT, Uric Acid, Bilirubin Level
 Chest Radiographic  Early Treatment And End Of Treatment
IP Ex :
 Explain About Disease
 Explain About Treatment And Side Effect Of Drug
 Consume Drug Regularly
 Use Mask For Prevent Transmission
 Choose Someone As A Treatment Controller
 2. PLEURAL EFFUSION
• Ass:
 Transudat  Sirosis Hepatis, Nefrotik Syndroma, Dialisis Peritoneum, Hipoalbuminemia,
Glomerulonefritis, Emboli Pulmonal, Atelektasis Paru, Hidrotoraks, And Pneumotoraks
 Exudat  Pneumonia, TBC, Ca.Paru, Trauma
• IP Dx :
 Rivalta Test
• Ip Tx :
 Pharmacology : -
 NonPharmacology :
O2 canule 3L/minutes
OAT

• IP Mx :
• Monitoring vital sign
• IP Ex :
Explain About His Diseases, Bed Rest
 3. HIPERKALEMI
Ass:
Arrhythmias
IP Dx : ECG
IP Tx :
Non Pharmacology : -
Pharmacology :
Calcium Gluconas 10 ml in 10% solution
Humalog 3 x 10 unit
NB Salbutamol 10 mg
IP Mx :
 ECG
 Potassium Monitoring
 Glucose
IP Ex : Explain About His Diseases, Bed Rest
 4. DISPEPSIA
Ass:
 Functional dispepsia (Post prandial distress syndrome, epigastric pain syndrome)
 Organic dispepsia (duodenal ulcer, gastric ulcer, gastritis)
IP Dx :
 Kontras OMD, endoskopi, urea breath test, PPI Test
IP Tx :
 Pharmacology
Omeprazole 20 mg 2x1
Ondansetron 3x4mg
Sukralfat syr 3x1 C
 Non pharmacology
Reduce fiber food, spicy and acid food
Avoid alcohol, soda
Reduce emotional stress
4. DISPEPSIA
IP.Mx :
 Dehidration state, general examination (ikterik, odinofagia, vomitus, nausea,
limfadenopathy, hematemesis/melena without etiology)
 Hb
IP.Ex :
 Reduce eat spicy, acid and fatty food
 Avoid alcohol, soda
 Reduce emotional stress
 Increase diet frequent with small portion
 5. HIPONATREMI
Ass : - IpMx :
 Elektrolit
IP Dx : -
IpEx :
Ip Tx :
 Avoid type of drugs that
 Non Pharmacology : can affect natrium
Diet fluids decrease
Pharmacology
NaCl 9%
Koreksi na+ dengan kecepatan koreksi 0,5-1 meq/l/jam.
(140-130,1)x 55 x 0,6 =326,7
KOMPOSISI: NA: 154 Mmol/L , Cl: 154 mmol/L
2 flask
 6. HIPERGLIKEMI
Ass : DM & non DM
IP Dx : GDP, GD2PP, TTGO
Ip Tx :
 Non Pharmacology :
Lifestyle management
 Medical nutrition theraphy
Exercise

Pharmacology : -
IP Mx : Blood glucose
IP Ex :
Explain to patients about the condition, and complication that may occur
 Controlling dietary habits
 Reduce glucose intake
 Exercise
 7. HIPERBILIRUBINEMIA
Ass :
Non Pharmacology :
1. Intrahepatal
Low fat intake
2. Ekstrahepatal
IP. Mx : vital sign, bilirubin,
IP Dx : gamma gt, alkali fosfatase, test serology
hepatitis virus (anti HAV, anti HBV, HCV RNA IP.Ex :
kualitatif), ultrasound, biopsi hati. Diet low fat
Routine check of bilirubin
IP Tx :
Pharmacology :
Curcuma 3X1
Guidelines
TUBERCULOSIS
Tuberculosis
EFUSI PLEURA
HIPERKALEMI
DISPEPSIA
 Alarm symptom for dispepsia
1. Decreasing of weight gain > 10% without any reason
2. Progressive disfagia
3. Vomitus frequent
4. Gastrointestinal bleeding
5. Anemia
6. Fever
7. Epigastrium mass
8. Family history of ca gaster
9. Acute dispepsia on age 45
HIPERBILIRUBIN
Pathophysiology
The classic definition of jaundice is a serum bilirubin level greater
than 2.5 to 3 mg per dL (42.8 to 51.3 μper L) in conjunction
with a clinical picture of yellow skin and sclera. Bilirubin metabolism
takes place in three phases—prehepatic, intrahepatic, and posthepatic.
Dysfunction in any of these phases may lead to jaundice.
HIPERGLIKEMI