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

History of
Present Illness

Abdominal pain
Patient came into the Policlinic
of Islamic Hospital of Sultan
Agung Semarang Complained
about his abdominal pain about
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

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

Intepretation :
Intepretation :
NormoWeight
NormoWeight

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

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 (-)

Palpable pain(-), tumor (-), enlargement of ICS

Palpable pain (-), tumor (-), Stem

(-), Stem fremitus Decrease (+)right

fremitus Decrease (-)

Dynamic

Palpation

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

Uric Acid

6,9 mg/dL

Total Protein

7,05 g/dL

Albumin

2,44 g/dL

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

24/11/2016

Imunoserologi

HbsAg Kualitatif

Non-reaktif

24/11/2016

Imunoserologi

GDS

95

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

History
Taking
1. Abdominal
Pain
2. Dyspneu
3. Weak
4. Nausea
5. Vomiting
6. Black
defecate

Physical
Examination
7. Icteric sclera
8.Jaundice
9.Shifting dullness
10. Chest Pain
(lower right)
11. Defans
muscular
12.Oedem lower
extremity
13. Peristaltic
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
Result

Laboratory finding

20. Anemia
Hb 12,3 g/dl
Ureum 55 mg/dL
Creatinin darah 1,39 mg/dL
SGOT 499 mg/dL
SGPT 75 mg/dL
Albumin 2,44 g/dL
Natrium 133,1 mmol/L
Kalium 5,2 mmol/L

21. Uremia
22.Transaminase Liver Increase
23. Hipoalbuminemia
24. Hiponatremia
25. Hiperkalemia

PROBLEMLIST
LIST
PROBLEM
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
Bed Rest

Pharmacology
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
Low Sugar Intake

High Fiber diet

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
albumin 25 % in 100cc = 12,5
mg

25 % in 100cc x 2 kolf

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