CASED BASED

DISCUSSION
Advisor : dr. HJ. Nur Anna C.S, Sp. PD, FINASIM

RIZANIA RAUDHAH NISFITA

30101507545

Department of Internal Medicine Faculty of Medicine

Sultan Agung Islamic University
2020
 TOPIC DISCUSSION
Patient Presentation
01 chief complaint, history of the present
illness, physical examination and laboratory
results

02 Assesment

03 Initial Plan
 Patient Identity

• Address: Sayung, Demak

• Name: Ms. RA
• Occupation: housewife
• Patient ID: 01407xxx
• Room: B. Izzah 1
• Age: 25 years old • Date of Examination:
• Sex: Female 26 February 2020
• Religion: moslem • Class: BPJS non PBI
 History of Present Illness
• Chief Complaint: Enlarge Abdomen
25 years old woman came to emergency room Sultan Agung
Islamic Hospital, complaints that her stomach enlarged since
1 month ago and it goes slowly. The patient's stomach also
aches on the right side. Severe pain is felt for the first time
but but the pain decreases along with enlarge abdominal.
Patients also complain of pain when fart. There are no comp
lain om urination and defecate.In addition the patient also co
mplained of frequent coughing when supine but reduced wh
en changing positions. She uses birth control 1 month after
giving birth her son 6 month ago. She used it twice.
Previous Medical History

History of previous History of family

Socio-economic history
Illness Illness

• Same symptom/
illness (-) • Cardiac Disease (-)
• Hospital cost certified
Hypertension history • Hypertension (-)
(-) by BPJS non-PBI
• Asthma and allergy
• Asthma history (-) history (-)
• COPD (-) • DM (+)
• Drug allergy (-)
• DM (-)
 DATE : 26th February 2020

GENERAL Awareness : composmentis

Vital sign
PHYSICAL BP : 123/83 mmHg
EXAMNATION Pulse : 128 x/minute
Temperature : 36.7 oC
Respiration Rate :20 x/minute
GENERAL STATUS
Skin : jaundice (-), pale (-)
Head : headache (-), Mesocephal, alopesia (-)
Eyes : Anemic conjuntiva(-/-), Icteric sclera(-/-)
Ears : discharge (-)
Nose : nosebleed (-), discharge (-)
Mouth : cyanosis (-), thrush (-)
Throat : swallowing pain(-), hoarseness (-)
Neck : trachea deviation (-), lymph hypertrophy (-),
JVP (normal) enlarged thyroid gland (-), bruits (-)
Chest : cough (-), sputum (-). Blood (-)
Cardiac : chest pain (-), palpitations (-)
Digestive : abdominal pain (-), nausea vomiting (-)
Musculoskeletal : weak (-), rigid (-), back pain (-)
Extremity : extremity edema (-)
CHEST EXAMINATION
(LUNG ANTERIOR)
EXAMINATION ANTERIOR POSTERIOR

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

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
 EXAMINATION ANTERIOR POSTERIOR

Inspection – Dinamic Up and down of hemithorax D=S Up and down of hemithorax D=S
Muscle retraction of breathing (-) Muscle retraction of breathing (-)
Retraction ICS (-) Retraction ICS (-)

Palpation Tenderness (-), Mass (-) Tenderness (-), Mass (-)

tactile fremitus (dextra>sinistra) tactile fremitus dextra > sinistra
Percussion Sonor (+) Dullness from T6 (+)
Auscultation Vesicular unttil costa 6(+), Whezzing (-), Vascular until T5, vascular decrease
Ronchi(-) From T6-T10, Whezzing (-), Ronchi(-)
 THORAX – COR EXAMINATION
INSPECTION Ictus cordis isn’t seen.
PALPATION Palpable (-), parasternal impulse (-), sternal lift (-), epigastrium impulse
(-)
PERCUSSION  Unknown

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 : (-)
 ABDOMINAL EXAMINATION

EXAMINATION RESULTS
Inspection Symetrical, cicatrix (-), Striae (-), Vein’s enlargement (-),
Caput medusa (-), Spider nevi (-), Convex(+)

Auscultation Peristaltic (+, 8x/menute), Abdominal aorta’s bruits (-)

Percussion Dullness, Shifting dullness(+), Liver dullness (-),
Liver span (-), Traube’s space (-)

Palpation Mass (-), Pain (+), Hepatomegaly (unknown),

Liver (unknown) Kidney (unknown) & Spleen (unknown),
Splenomegaly (-),
Murphy’s sign (-), Undulation test (+)
EXTREMITY EXAMINATION

SUPERIOR INFERIOR
Edema -/- -/-
Cold -/- -/-
Pathological Reflex -/- -/-
Physiological Reflex +/+ +/+
Jaundice -/- -/-
LABORATORY EXAMINATION
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LABORATORY
25th February 2020 EXAMINATION
Test Result Normal Baseline
HAEMATOLOGY TEST

Hemoglobin 9.7 mg/dl 11.7 – 15.mg/dl

Hematokrit 32.5 % 33 – 45 %
Leukosit 7.31 ribu/uL 3.6 – 11.0 ribu/iL
Trombosit 814 ribu/uL 150 – 440 ribu/uL
BLOOD CHEMICAL TESTS
Urea nitrogen (BUN) 14 mg/dl 10 - 50mg/dl
Creatinin 0.62 mg/dl 0.6-1.1 mg/dl
Total protein 6.86 g/dl 6.0 – 8.0 g/dl
Albumin 3.08 g/dl 3.4 – 4.8 g/dl
THORAX X PHOTO

CONCLUTION :
Cor difficult to judge
Pulmo that can be seen normally
Left pleural effusion
ULTRASONOGRAPHY
CONCLUTION :
Hepar, Ren, Lien, Pancreas normal
Uterus Normal
No sign of mass on regio adneksa
Ascites
Effusi Pleura Sinistra
DATA ABNORMALITY
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DATA ABNORMALITY
Physical
History Taking Examination

5. Pulmo posterior, palpation tactile fremitus dextra >

sinistra
1. Enlarge Abdomen 6. Pulmo posterior, auskultasi Vascular until T5, vasc
2. Pain in abdomen Dextra ular decrease From T6-T10
3. Hard Farting 7. Pulmo posterior, palpation Dullness from T6
4. Cough when supine 8. Abdomen inspection Convex
9. Abdomen percution Dullness, Shifting dullness(+)
10. Abdomen palpation, pain, Undulation test (+)
 Laboratory
Examination
11. Blood examination
Hb : 9.7 mg/dl LOW
HT :32.5% LOW
Albumin : LO
Trombosit : 814 ribu/uL
12. Thorax X Photo
Left pleural effusion
13. USG
Acites (+)
Left pleural effusion
PROBLEM LIST
Left Pleura Effusion

Acites

Anemia

Hipoalbumin
Left Pleura Effusion
Assessment
IPMx:
Etiology :
Transudat , Liver Cirrhosis Hepatis, CHF,  Vital sign
Nephrotic Syndrom, Dyalisis Peritoneum,
Hipoalbuminemia, etc  Xray Thorax

IPDx:
Rivalta Test
Protein level & LDH level in effusion IPEx:
IPtx: • Explain pleural effusion
• Bed Rest
Pharmacology • Avoid heavy activities
- Furosemid inj 1x40mg
Non Pharmacology
- Pleural punctum
Ascites
Assesment
Transudat, eksudat Ip Mx
Darah rutin , chemistry blood
Ip Dx (ureum, creatinin, albumin,
px. SAAG ( Serum Acites Albumin Gradient) globulin, totalprotein),
IP. Tx
Non Farmakology: Diet enough salt 2 gram/ day
Ip Ex
Diit low liquid 1 liter/ day
bed rest, reduce dringking
Farmakology : inj Furosemid 3 X 10 mg/ml
and salt
spironolacton 3 X 100mg tab
Anemia
Assessment:
• Anemia mikrocytic hipochromic IPTx:
• Iron deficiency • Sulfas Ferrous 2x100
• Beta Thalasemia minor
• Alpha Thalasemia minor
IPMx:
• Anemia normositic normocromic
• Awerness
• Haemolytic anemia • Vital Sign
• Hypoplastic / aplastic anemia • Complete blood count (Hb, Ht)
• Chronic disease
• Blood lost
• Anemia makrositic IPEx:
• Vitamin B12 and folate deficiency. Bed Rest
Explain about Anemia
IPDx: Explain about treatment of Anemia
• Eritrocyte index(MCV, MCH, MCHC)
• Reticulosit
• Unconjugated bilirubin
• Coombs test
Hypoalbunemia
IP Dx
- Albumin count
IP Rx:
Albumin correction  (Albumin target – Alb actual) x BB x 0.8 = (gr)
Alb corr : (3.5 – 3.04) x 55 x 0.8 = 20.24 gram

IP Tx :
- Po Inbumin 2x2
IP Mx:
- Albumin count
IP Ex:
- High intake protein
 ‫َما أ َ ْنزَ َل هللاُ َدا ًء ِإ اَّل أ َ ْنزَ َل ََُُ ََِِا ًء‬
"God does not bring down disease
unless He also lowers its antidote." (HR Bukhari).