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CASE BASED DISCUSSION

Diajukan untuk Memenuhi Tugas Kepaniteraan Klinik dan Melengkapi Salah Satu Syarat Menempuh Program Pendidikan Profesi Dokter Bagian Ilmu Penyakit Dalam Di Rumah Sakit Islam Sultan Agung Semarang

CASE BASED DISCUSSION Diajukan untuk Memenuhi Tugas Kepaniteraan Klinik dan Melengkapi Salah Satu Syarat Menempuh Program

Disusun oleh:

Dzikril Hakim

01.211.6373

Pembimbing:

dr. Lusito, Sp.PD

BAGIAN ILMU PENYAKIT DALAM FAKULTAS KEDOKTERANUNIVERSITAS ISLAM SULTAN AGUNG SEMARANG

2015

CASE REPORT

A.

Patient`s Identity

:

:

 

Name

Mr. S

Age

58 years old

Gender

:

Male

Religion

:

Islam

Job

: Farmer

Address

: Mojodemak, Demak

MR number

:

01263541

Room

:

:

Baitul izzah 1

Check in date

9/9/2015

Check Out date

:

12/9/2015

B.

Data

1.

Anamnesis

Main Problem : Abdominal Pain

o

History of Present Illness

Patient came to RSISA on 9 September 2015 with abdominal pain in upper left abdomen since 1 week ago. He also complain about nausea and vomiting. The abdominal pain appear everytime but in last 4 days the complain more painful. The complain better if resting and worsening when he doing activity. He ever go to doctor but the complain still remaining.

o

History of previous illness

Hypertention (-)

DM (-)

Alcohol (-)

Maag (+)

Hepatitis (-)

Smoking (+)

o

Family’s history of disease

 

Hypertention (-)

DM (-)

Maag (-)

Hepatitis (-)

o

Sosio-Economic History :

Hospital cost certified by GENERAL

  • C. Systemic Anamnesis

o

General

: weak

o

Skin

: itching (-), jaundice (-), pale (-)

o

Head

: headache (-)

o

Eyes

: blurred vision (-), red eyes (-), icteric sclera (-/-)

o

Ears

: hearing loss (-), discharge (-)

o

Nose

: nosebleed (-), discharge (-)

o

Mouth

: cyanosis (-), thrush (-), bleeding gums (-)

o

Throat

: pain swallow(-), hoarseness (-), difficult inswallowing (-)

o

Neck

: enlargement of the gland (-), nape pain (-)

o

Chest

: cough (-), sputum (-), blood (-)

o

Cardiac

: chest pain (-)

o

o Digestive : abdominal pain (+) at the upper left region, decreased appetite (+), nausea (+), vomiting (+), defecate/micsi (+/+) Musculosceletal : weak (+), rigid (-), back pain (-)

o

Extremity

: oedem inferior extremity (-)

  • D. Physical Examinations General Status

General

: Weak

Awareness

: composmentis

Vital Sign Blood Pressure

: 110/80 mmHg

 

Heart rate

 

: 70 x/minutes, reguler,

adequate amplitudo, same

equality,

 

elastic artery wall, pulsus

 

alternans

(-),

pulsus

 

defisit (-) Breath : 18x/minutes

 

Temp

 

:

36 o C

 
 

Head

: Mesocephal, alopesia (-)

 

Eyes

: Anemic Conjuntival (-/-), Icteric sclera(-/-)

Nose

: symmetric, secret (-), Nostril Breath (-)

Ears

: Normal Shape, discharge (-/-)

Throat : Hyperemic (-), pain devour (-)

 

Mouth : Cyanosis (-), dry lips (-),

 

Neck

: Trakhea deviation (-), Lymph Hypertropy (-)

 

Extremity

: Oedem of lower extremity (-), Oedem of upper extremity (-)

 

a.

PF thorax

 

Pulmo:

 

INSPEKSI

 

ANTERIOR

 

POSTERIOR

 
 

Static

 

RR

:

18x/min,

RR

:

18x/min,

 

Hyperpigmentation (-),

tumor

Hiperpigmentasi (-), tumor

(-), inflammation (-), spider nevi

(-), inflammation (-), spider

(-),

Hemithorax

D=S,

ICS

nevi (-), Hemithorax D=S,

Normal, Diameter AP < LL

ICS Normal, Diameter AP <

 

LL

 

Dinamic

 

hemithorax movement D=S, abdominothorakal breathing, (-), muscle retraction of breathing (-), retraction ICS (-)

hemithorax movement D=S, abdominothorakal breathing, (-), muscle retraction of breathing (-), retraction ICS (-)

 

Palpation

 

Palpation

pain

(-),

tumor

(-),

Palpation pain (-), tumor

 

Arcus

costae

angle

<

90 0 ,

(-), enlargement of ICS (-),

enlargement of ICS

(-), Stem

Sterm fremitus D=S

fremitus D=S

 
 

Percussion

 

Dextra:sonor Sinistra : sonor

Dextra : sonor Sinistra : sonor

 
 

Auscultatio

 

ronchi (-), wheezing (-/-)

ronchi (-), wheezing (-/-)

n

Cor:

Inspection

:

Ictus cordis isnt 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 parasternalis line

Lower right borderline of heart

:

ICS V right sternal line

Lower left borderline of heart

:

ICS

V,

2

cm medial from

left mid

clavicle line 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 (-)

  • b. Abdomen

 

Inspection

: symetric, sycatric (-),striae (-), scuama (-), enlargement of

vena (-), hiperpigmentasi (-). Spider nevi (-)

 

Auscultation

:peristaltic (+) Normal (20 x/ minutes)

 

Palpation

 

Superfisial

: massa (-), abdominal pain (-)

 

Deep

 

:abdominal

pain

(+),hepatomegali

(-).

splenomegali

(-),

 

Murphy’s sign (-)

 

Percussion

 

Liver

 

: tympani, side of deaf (-), shifting dullness (-) : deaf(+), liver span dextra 7 cm, liver span sinistra 5 cm

Spleen

:Throbe space percussion (+) tympani

  • c. Extremities

 
 

Extremity

superior

inferior

-

Oedem

 

-/-

-/-

-

cold extremities

-/-

-/-

-

Physiological reflex

+/+

+/+

-

Icteric

 

-/-

-/-

Laboratory`s Examination

HEMATOLOG Y Hemoglobin

: 16,7 g/dl

Hematokrit: 48,4%

Leukosit

: 7,6 ribu/uL

Trombosit : 263 ribu/ uL

CHEMISTRY Ureum Creatinin SGOT SGPT Natrium Kalium Cloride IMUNOSEROLOGI HbsAg Kualitatif

: 22 mg/dl : 0,93 mg/dl : 21 U/l : 22 U/l :143,4 mmol/L :4,40 mmol/L :99,1 mmol/L

Non Reaktif

Thorac X-ray

Thorac X-ray Kesan :  Cor normal  Elongasi aorta  Pulmo normal

Kesan :

Cor normal

Elongasi aorta

Pulmo normal

CT Scan Abdomen

CT Scan Abdomen Kesan: Hepar, lien, ginjal, pancreas normal E. Data of Abnormality Anamnesis: • Abdominal

Kesan:

Hepar, lien, ginjal, pancreas normal

  • E. Data of Abnormality Anamnesis:

Abdominal pain in upper left abdomen

Nausea

Vomiting

Physical Examination:

Abdominal pain in hipocondriaca sinistra

Advance Examination:

-

F.

Problem List 1. Dispepsia Discussion

:

 

Dispepsia Ass

Dispepsia fungsional ( tidak ada kelainan organ) Dispepsia organik à Gastritis Tukak gaster Tukak duodenum

IP Dx :

 

Endoskopi

 

Ip Tx

:

Non Farmacology

Tirah baring Farmacology Inj. Pantoprazol

 

Paracetamol 3 x 1

Braxidin 3 x1

Ulsidex 3 x 1

IP Mx: vital sign

IP Ex:

Eat regulary

Not eat sour and spicy, coffee

Avoid cigarette

Consumption drug regularly

Bed rest