CASE BASED DISSCUSION

SUPERVISOR
DR. NUR ANNA C. SA’DYAH,SP.PD, FINASIM
By Nina Oktarina Y (30101407269)

Department of Internal Medicine Faculty of Medicine Sultan

Agung Islamic University
2019
1.Identifying information/chief
complaint
2.History of present illness
3.PMH, Meds,
4.Physical examination (key findings
only)
5.Laboratory
6.Assessment and plan
PATIENT’S IDENTITY
Name : Mrs. R
Age : 55 years old
Sex : Female
Religion : Moslem
Job : Housewife
Address : Jl. Kudu Baru
No.RM : 01-09-xxxx
Room : Poly
Date of examination : 23 Oct , 2019
 HISTORY TAKING
Main Problem limp /weakness

History of
Present
Illness
Patient came to internal medical clinic of Sultan Agung
Hospital Semarang with dizzines since a 3 day ago.
Complaint of pain in her left leg. Another complaint that is
felt is limp, frequent urination, and tingling on the feet. The
patient felt she has a weight gain. The patient also
complained of deformity in the left leg that cause the
patient to have difficulty walking. Patients have a history
of DM, hypertension, and hiperkolestrol.
 HISTORY OF ILLNESS
Family’s history of disease

History of previous illness • Hypertension history (+)

• DM history (+)
• Same symptom/illness (+) • Asthma and alergy history (-)
• Hypertension history (+)
• DM history (+)
• Asthma history (-)
• Alergy history (-)
• Cardiac Disease (-) Sosio-Economic History
• Drug allergy (-)
• Economic Impression : enough
GENERAL PHYSICAL EXAMINATION
DATE : 23 Oct 2019

• General : limp/weakness BMI (Body Mass Indeks)

• Awareness : composmentis
Weight : 61 BMI=
• Vital sign :
High : 156
BP = 258/123 mmHg
Pulse = 102 x/menit
RR = 22 x/menit Interpretation = obesitas
T = 36.5 0C
◦ Waist circumference :
• Head : Mesochepal, alopecia (-)
• Eyes : Anemic conjuntiva(-/-), Icteric sclera(-/-)
• Nose : Symmetric, secret (-), Nostril Breath (-)
• Ears : Normal shape, discharge (-/-)
• Mouth : Cyanosis (-), dry lips (-), snoring (-)
• Neck : Tracheal deviation (-), Lymph Hypertrophy (-)
• Extremity : Oedem of lower extremity (+), Oedem of upper
extremity (-)

Interpretation = normal
 CHEST EXAMINATION - LUNG
EXAMINATION ANTERIOR POSTERIOR
Inspection - Static RR : 22x/min RR : 22x/min
Thoracal breathing Thoracal breathing
Hyperpigmentasi (-) Hyperpigmentasi (-)
Spider nevi (-) Spider nevi (-)
Atrofi M. Pectoralis (-) Hemithoraks D=S
Hemithoraks D=S ICS Normal
ICS Normal Diameter AP < LL
Diameter AP < LL
Inspection - Up and down of hemitoraks D=S Up and down of hemitoraks
Dinamic Muscle retraction of breathing (-) D=S
Retraction ICS (-) Muscle retraction of breathing
(-)
Retraction ICS (-)
 EXAMINATION ANTERIOR POSTERIOR
Palpation Palpation pain (-) Palpation pain (-)
Mass (-) Mass (-)
Sterm fremitus D=S Sterm fremitus D=S
Percution Sonor (+) Sonor (+)
Auscultation Vesicular (+) Vesicular (+)
Whezzing (-) Whezzing (-)
Ronchi basal(-) Ronchi basal(-)

Interpretation = normal
 THORAX - COR
INSPECTION Ictus cordis isn’t seen.
JVP increase

PALPATION Ictus cordis is palpate at SIC VI linea mid clavicula sinistra

thrill (-)
pulsus epigastrium (-), pulsus para-sternal (-), sternal lift (-).

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, 2 cm medial from linea mid
clavicula sinistra
AUSCULTATION - Aortal valve : S1 & S2 standard, additional sound (-)
- Pulmonary valve : S1 & S2 standard, additional sound (-)
Interpretation = normal - Tricuspid valve : S1 & S2 standard, additional sound (-)
- Mitral valve : S1 & S2 standard, additional sound (-)
 EXAMINATION RESULTS
Inspection Simetrics
A Sycatric (-)
Striae (-)
Enlargement of vena (-)
B Caput medusa (-)
Spider nevi (-)

D Auscultation Peristaltic (+)

Aorta abdominal bruit (-), A. Lienalis, A. femoralis (-)
Percussion Shifting dullness(-)
O Undulation test (-)
Hepar deaf (-)
Liver span dextra 11 cm

M Liver span sinistra 6 cm,

Traube’s space (+)
Palpation Mass (-)
E Pain (-)
Hepatomegali (-)
Hepar, kidney & lien are normal
N Splenomegali (-)
Murphy’s sign (-)
Interpretation = normal
 EXTREMITIES
Superior Inferior
Oedem -/- +/+
Cyanotic -/- -/-
Cold Extremity -/- -/-
Capillary Refille <2” <2”
Clubbing Finger -/- -/-
Physiologic Reflex +/+ +/+

Pathologic Reflex -/- -/-

Interpretation = normal
 SUPPORTING EXAMINATION
DATE : 23 Oct 2019

GDS : 348 mg/dl

Trigliserid : 625
LDL : 258
Hba1c : 13,75
 ABNORMALITY DATA
Anamnesis
1. Limp/weakness
2. dizziness
3. Tingling on the feet
4. weight increase
5. Deformity at left leg cause Supporting Examination
difficulty walking
6. DM History 8. GDS 348 mg/dl

Physical Examination
7. Overweight
 PROBLEM LISTS
HT emergency &
DM Sindrom Metabolik
Dizzines
Tingling on the feet
Limp/weakness Overweight
DM History Frequent urination
Overweight
GDS 220
TD : 358/123
Assesment
HT emergency with DM
DD : HT emergency, impaired glucose tolerance, interrupted fasting blood glucose, and
hyperglycemia crisis
Complication :
Microangiopathy : Retinopathy, Nefropathy
• Macroangiopathy : coronary heart disease, cardio vascular disease, peripheral arterial
disease
• Neuropathy : otonom neuropathy, motoric neuropathy, and sensoric neuropathy
Emergency : Diabetic Ketoacidosis
Ip. Dx :
Random Blood glucose, A1c, Funduscopy, EKG, Ureum Creatinin, BGA test,
Ip.Tx :
Non pharmacological treatment
◦ balanced nutrition therapy
◦ Low sugar diet
Exercise : 30 minutes a day
Pharmacology
• Metformin 500 mg 1x1 (night)
Ip. Ex :
• Captopril 2 x 50 mg
• Follow a healthy diet (type,
• Herbeser cd 200 1x1 total, and schedule of food)
• Extra nifedipin 10 mg • Increase physical activity
• Use diabetes medications
• Atorvastatin 1x 20 mg and medications in special
• Acarbose : 2x100mg conditions safely and
regularly.
• Humalog 3x24 • Monitoring Mandir Blood
◦ Ip.Mx: Glucose (PDGM)
• Having the ability to
GDS, vital sign, clinical patient, BGA test
recognize and deal with
acute conditions
appropriately.
 METABOLIC SYNDROME
◦ Assesment :
Dd : Sindroma metabolik, DM,
Hyperlipemia, Hypertriglycerid, Ip Mx : GDS, clinical patient, kolestrol
Complication : Heart atack, stroke Ip. Ex :
Ip. Dx : hematologic routine, Cholestrol, ◦ Contact foot health and hygiene
triglycerid, A1C
◦ Exercise 30 minutes a day
Ip. Tx :
◦ multiply the consumption of fruits and
Atorvastatin 1x20 mg vegetables
Hypertensive drug ◦ Take medication regularly
DM drug
Thank you ..
Questions
◦ 1. what are the symtomps bout metabolic syndrome (fikri)
◦ 2. is there Laboratory examination of the metabolic sindrom (fikri)
◦ 3. what are the differentiation between ht emergency and ht urgency (basu)
◦ 4. what are the risk factor of metabolic syndrome (basu)
◦ 5. why did you give the farmacoteraphy in this case ( uno)
◦ 6. what kind of exercise you give to this patient (uno)
◦ 7. how many calories you will calculateto this patient (tika)
◦ 8. how the principle therapy for DCA (tika)
◦ 9. how to established metabolic sindrom (fatia)
◦ 10. what is criteria to discharge patient with metabolic syndrome (fatia)
◦ 11. what a treatment of HT emergency (minachun)
◦ 12. what is target of therapy to reduce HT emergency
◦ 13. how to prevent metabolic sindrom (diva)
◦ 14. what is a target of the random blood glucose of this patien (diva)
◦ 15. what is the correlation between MS with Dm and Ht ( made)
◦ 16. how to educate the patient to lost the weight because patient cannot walking (
made)
◦ 17. what is the complication of SM (dina)
◦ 18. how to manage quality of live to secondary and tertiary prevention DM and HT
patient
◦ 19. what the prognosis of this patient ( mita)
◦ 20. why the patient given nipedipin for therapy (syifa)
◦ 21. what kind of nutrition you advise to patient
◦ 22. what are the criteria of MS according to NCEP ATP 3 (nana)
◦ 23. what are classification of crisis hypertention (aufa)
◦ 24. what a symptom of HT emergency
◦ 25. what the life style educate to this patient (galuh)
◦ 26. what the diit for this patien
◦ 27. when the patient HT emergency going to the hospital (bagus)
◦ 28. when the patient HT emergency sending home ?
◦ 29. what is the actual main problem of this patient ? (ale)
◦ 30. how to mange about hypertigliserid on this patien ?
◦ 31. what are the various type of HT medicine ?
◦ 32. what is the first line for the patient
◦ 33. what condition parenteral medication should be given to this patient (barun)
◦ 34. how to manage this case with islam perfective
◦ 1. how to comparison about MS , hyperlipidemia, hypertrigliserid, dyslipidemia
◦ 2. how to reach the target of trygliseridemia level with pharmacological and non pharmacological
◦ 3. What is the reason simvastastin as
◦ 4. explain about anti livid drug from statin group
◦ 5. please explain about antilivid drug for anti trigliseridemia
◦ 6. can you combained antilivid drug with anti hypertriglisrid drug and give your reason
◦ 7. what are the reason of insulin treatment and what the reason you give Humalog
◦ 8. why did you choose the Humalog
◦ 9. how to deliver insulin in this patient
◦ 10. what are the side effect of insulin and how to manage it
◦ 11. please explane about pharmacology of acarbose and what is the indication and side effect of it
◦ 12. how to measure circurference order to good manual
◦ 13. how to reach the goal of a1c , LDL, trygliserid, fasting plasma glucose, and gd2pp in order to guidline to
preventient and manage update DM tipe 2 perkeni
◦ 14. what are qur’an says about how to eat food well in order to rasulullah