CASE BASED DISCUSSION

Submitted for
Fulfill the Clinical Rotation Assignment in Internal Medicine Department
At Sultan Agung Islamic Hospital Semarang

by:

Rizkia Amal Ramadhani

30101407312

Supervisor:

dr. Nur Anna C. Sa’adyah, Sp.PD, FINASIM

DEPARTMENT OF INTERNAL MEDICINE

FACULTY OF MEDICINE SULTAN AGUNG ISLAMIC UNIVERSITY
SEMARANG
2019
 CASE REPORT

I. PATIENT’S IDENTITY
Name : Mr. MI
Age : 53 years old
Gender : Male
Religion : Moslem
Adress : Lengkong RT/RW 01/07 Sayung, Demak
Occupation : Trader
Room : Baitul Izzah 1 – I6
Medical Record : 01402XXX
Examination Date : 6th January 2020

II. HISTORY TAKING

Main Problem : a wound on his feet
History of present illness :
A 53 years old Men came to Internal Medicine Policlinic Sultan Agung Islamic Hospital,
complains that he has wound on his feet since 2 weeks before came to the hospital. He
never give a treatment for his wound, as time goes by the wound became a bulla. He said
that he is diagnosed by the doctor with diabetic mellitus since 1 year ago, but he never
take a medicine for his condition.
History of previous illness
• Same symptom/illness (-)
• Hypertension history (-)
• DM history (+) since 2019
• Asthma history (-)
• Alergy history (-)
• Cardiac Disease (-)
• Drug allergy (-)
Family’s history of disease
• Hypertension history (-)
 • DM history (+)  his mother
• Asthma and alergy history (-)
Sosio-Economic History
• Hospital cost certified by BPJS NON PBI

III. GENERAL PHYSICAL EXAMINATION

DATE : 7 January 2020
 Awareness : composmentis
 Vital sign :
BP : 141/70 mmHg
Pulse : 84 x/minute
Temperature : 36 oC
Respiration Rate :20 x/minute
 BMI (Body Mass Index)
Weight : 63 kg
High : 165 cm
BMI : 23.14 (Normoweight)
 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 (-), JVP (normal)
 Chest : cough (-), sputum (-). Blood (-)
 Cardiac : chest pain (-), palpitations (-)
 Digestive : abdominal pain (-), nausea vomiting (-)
 Musculoskeletal : weak (-), rigid (-), back pain (-)
 Extremity : extremity edema (-), bulla (+)
Interpretation : Bulla on extremity
IV. CHEST EXAMINATION – LUNG

EXAMINATION ANTERIOR POSTERIOR

Inspection – RR : 20x/min RR : 20x/min

Static Thoracal breathing Thoracal breathing
Hyperpigmentation (-) Hyperpigmentation (-)
Spider nevi (-) Spider nevi (-)
Atrophy M. Pectoralis (-) Atrophy M. Pectoralis (-)
Hemithorax D=S Hemithorax D=S
ICS Normal ICS Normal
Diameter AP < LL Diameter AP < LL

Inspection – Up and down of hemithorax Up and down of

Dinamic 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 (+), Whezzing (-), Vesicular (+), Whezzing
Ronchi(-) (-), Ronchi(-)
Interpretation : NORMAL
V. THORAX – COR EXAMINATION
INSPECTION Ictus cordis isn’t seen.

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

PERCUSSION  Dullness
 Upper borderline : ICS II linea sternalis sinistra
 Waist borderline : ICS III linea parasternalis sinistra
 Lower right borderline : ICS V linea sternalis dextra
 Lower left borderline : ICS V, 2cm lateral from linea mid
calvicula sinistra
AUSCULTATION - Aorta valve : SD I-II no abnormalities
- Tricuspidal valve : SD I-II no abnormalities
- Pulmonal valve : SD I-II no abnormalities
- Mitral valve : SD I-II no abnormalities
- Murmur : (-)
- Gallop : (-)
Interpretation : NORMAL

VI. ABDOMINAL EXAMINATION

 EXAMINATIO RESULTS
N
Inspection Symetrical, cicatrix (-), Striae (-), Vein’s
enlargement (-), Caput medusa (-),
Spider nevi (-)
Auscultation Peristaltic (+), Abdominal aorta’s bruits
(-), A. Lienalis, A. femoralis (-)
Percussion Tympanic, Shifting dullness(-)
Undulation test (-), Liver deaf (-), 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 -/- -/-
Pathological Reflex -/- -/-
Physiological Reflex +/+ +/+
Jaundice -/- -/-
 Interpretation : Bulla on his right feet

VIII. LABORATORY EXAMINATION

Test Result Normal Baseline

Hematology

Hb 13.8 g/dl 11,7 – 15,5 g/dl

Hematocrit 39.1 % 33-45 %
Leukocyte 6.43 thousand/uL 3.6 -11.0 thousand/uL
Trombocyte 248 thousand/uL 150-440 ribu/uL
Random Blood Glucose 311 mg/dL 75 – 100 mg/dL
IX. ECG

Rhytm Sinus
Regularity : Regular
Frequency : 88 x/minute
Axis : lead 1 = +; AvF = +  NAD
Transition zone :-
P wave : 0,08 s (normal)
PR Interval : 0,16 s (normal)
QRS Interval : 0,06 s (normal)
Pathologic Q wave :-
ST Segment : elevated ST (-), depressed ST (-)
T wave : T flat (-), T tall (-), T inverted (-)

X. ABNORMALITY DATA
History Taking
1. Wound on his feet
Physical Examination
2. Blood pressure : 141/70 mmHg
3. Bulla on his feet
Laboratory Examination
 4. Random Blood Glucose = 311 mg/dl

XI. PROBLEM LIST

1. Type II Diabetes Mellitus
2. Bulla on feet
3. Hypertension garde I

XII. DISCUSSION
1. Type II Diabetes Mellitus
Assesment
Complication :
Microangiopathy : Retinopathy, Nephropathy
Macroangiopathy : Coronary Heart Disease, Cardiovascular disease, Peripheral
Arterial Disease

IP Dx :
HbA1c, Funduscopy, ECG, Ureum Creatinin, BGA test
IP Tx :
Non Pharmacological Treatment :
Balanced nutrition therapy
Low sugar diet
Pharmacological Treatment :
- Humalog 3x7 unit a.c 30 minutes
IP Mx:
Random Blood Glucose, Vital sign, Clinical Patient’s Condition, BGA test
IP Ex :
Follow a healthy diet (type, total, and schedule of food)
Increase physical activity
Use diabetes medications and medications in special conditions safely and regularly.
SMBG ( Self Monitoring Blood Glucose)
Having the ability to recognize and deal with acute conditions appropriately
2. Bulla on feet
Assessment : -
Initial Plan of Diagnosis : -
Initial Plan of Therapy
Non pharmacology : compress the wound using NaCl
Pharmacology : Ceftriaxone 2x1 inj
Initial Plan of Monitoring
- Wound condition
Initial Plan of Education
- Explain about the disease
- Explain about treatment for this condition

3. Hypertension grade I
Assessment :
- Emergency hypertension
- Urgency hypertension
- Benigna or maligna
Initial Plan of Diagnosis :
- Funduscopy
- Ureum creatinin
Initial Plan of Therapy
Farmachological Treatment :
- Captopril25mg 2x1
Initial Plan of Monitoring
- Vital sign
Initial Plan of Education
- Take medicine regularly
- Check clood pressure regularly
- Diet low salt