CASE BASED

DISCUSSION
Department of Internal Medicine
Faculty of Medicine Sultan Agung Islamic University
Sultan Agung Islamic Teaching Hospital
2021
 CLINICAL SUPERVISOR & CLERKSHIP
STUDENT& CLERKSHIP
CLINICAL SUPERVISOR
STUDENT

dr. Hj Nur Anna CS, Sp.PD, KEMD, FINASIM Robby Gunawan

, Sp.PD, KEMD, FINASIM. (30101607736)
Internist & Cardiovascular Consultant
(CLERKSHIP STUDENT OF
INTERNAL MEDICINE
(CLINICAL SUPERVISOR)
DEPARTMENT)
 PATIENT’S IDENTITY
• Name : Mr. A
• Patient ID : 01-40-XXX
• Age : 85 years old
• Sex : Male
• Religion : Moeslim
• Address :Kampung Geni besar, Semarang
• Occupation : Retired
• Room : Endocrine Clinic
• Date of Examination : 21/12/2021
• Class : BPJS Non PBI
 HISTORY TAKING
●MAIN PROBLEM

● Wet cough
●HISTORY OF PRESENT
ILLNESS
●The patient came to Endocrine clinic of Sultan Agung Islamic Hospital with the purpose of
monthly checkup due to diabetes type II which patient had over 17 years ago (2004). During
the visit patient also complain wet cough that has been felt by the patient since 3 weeks ago.
The wet cough is felt continuously and gets worse especially when the patient get up in the
morning and also during take a bath. Complaints of wet cough accompanied by greyish
sputum/phlegm.The patient itself sometimes also had tingling sensation on both feet. Other
symptoms like blurry vision, ulcer on extremities, decreased urine output were denied by
patient
 the patient's economic impression is sufficient

HISTORY OF ILLNESS
HISTORY OF HISTORY OF SOCIO-ECONOMIC
PREVIOUS FAMILY DISEASE HISTORY
ILLNESS
Same Illness: (+) 1 year ago Same Illness : (-)
• The patient's economic
Hypertension History: (-) Hypertension history : (+) Mother
impression is sufficient
DM History : (+) since 2004
DM History : (+) Mother • The patient use BPJS to
Cardiac Disease : (-)
Asthma History : (-) bear the hospital costs
Kidney Disease : (-)
Cardiovascular Disease: (-)
Allergy History : (-)
 01
PHYSICAL EXAMINATION
GENERAL PHYSICAL EXAMINATION

BMI (Body Mass Index)

DATE : 21 December 2021 Weight : 62 kg
◦ Awareness : composmentis Heigh : 168 cm
◦ Vital sign BMI : 21,96 (normal)

◦ BP : 135/76 mmHg Waist circumference: 94 cm

◦ Pulse : 84 x/minute
Interpretation =Normal
◦ Temperature : 36,8 C o

◦ Respiration Rate : 20x/minute

NUTRITIONAL STATUS BASED ON WHO AND
ASIA-PACIFIC GUIDELINES
 GENERAL PHYSICAL EXAMINATION
● Skin : itching (-), jaundice (-), pale (-).
● Head : headache (-)
● Eyes : blurred vision (-), Conjunctival anemic (-/-), Conjunctival Icterus (-/-)
● Ears : hearing loss (-), discharge (-)
● Nose : nosebleed (-), discharge (-)
● Mouth : cyanosis (-), thrush (-)
● Throat : swallowing pain (-), hoarseness (-), difficult in swallowing (-)
● cough (+), sputum (+). Blood (-)
● Neck : tracheal deviation (-), lymph hypertrophy (-), JVP (normal)
● Cardiac : chest pain (-), palpitations (-)
● Digestive : abdominal pain (-), bloated stomatch (-) , cicatrix (-)
● Musculoskeletal : weak (-), rigid (-), back pain (-)
● Extremity : edema(-) pain (-), tingling sensation (-)

Interpretation = cough
accompanied by sputum
 COR – THORAX EXAMINATION
EXAMINATION RESULTS
INSPECTION Ictus cordis isn’t seen.

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

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, 2cm lateral from linea mid calvicula sinistra

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 (-)

Interpretation = Normal
EXAMINATION ANTERIOR POSTERIOR

RR : 20x/min RR : 20x/min
Thoracal breathing Thoracal breathing
Hyperpigmentation (-) Hyperpigmentation (-)
Spider nevi (-) Spider nevi (-)
Inspection – Static
Atrophy M. Pectoralis (-) Atrophy M. Pectoralis (-)
Hemithorax D=S Hemithorax D=S
ICS Normal ICS Normal
Diameter AP < LL Diameter AP < LL

Up and down of hemithorax D=S Up and down of hemithorax D=S

Inspection –
Muscle retraction of breathing (-) Muscle retraction of breathing (-)
Dynamic
Retraction ICS (-) Retraction ICS (-)

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

Palpation
tactile fremitus ( /- ) tactile fremitus ( / - )
Percussion Sonor (+) Sonor (+)

Auscultation Bronchial ( /- ), Wheezing (-), Ronchi (+/-) Bromchial ( / -), wheezing (-), Ronchi (+/-)
Interpretation = Tactile fremitus ( /-), Bronchial breath sound ( / -),
Wet rochi ( /-)
 ABDOMINAL EXAMINATION
Inspection : Simetrics, Striae (-), Enlargement of vena (-), Caput medusa (-), Spider nevi (-)
Auscultation : Peristaltic (+), Aorta abdominal bruit (-), A. Lienalis, A. femoralis (-)
Percussion : Flat (+), Dull (+) Shifting dullness (-) Undulation test (-), Liver dullness (-), Liver
span (-), traube space (-)
Palpation
• Superficial : Abdominal tenderness (-), Mass (-), muscular defense (-)
• Deep : Abdominal tenderness (-), hepatomegaly (-), splenomegaly (-)

Interpretation : Normal
 EXTREMITY EXAMINATION
Superior (D/S) Inferior (D/S)

Oedema -/- -/-

Pitting Oedema -/- -/-

Cold Extremity -/- -/-

Warm -/- -/-

Pain -/- -/-

Numbness -/- +/+

Capillary Refille <2s <2s

Interpretation : Inferior extremity Numbness (+/+)

 02
ADDITIONAL
EXAMINATION
LABORATORY
 LABORATORY EXAMINATION

  Test Result Normal Baseline

Random Blood
370 75-110 
Glucose

Interpretation :
high random blood glucose levels
21/12/2021
 LABORATORY EXAMINATION

  Test Result Normal Baseline

Random Blood
252 75-110 
Glucose

Interpretation :
high random blood glucose levels
27/12/2021
   Test Result Normal Baseline
HbA1c 8,7 <7

Interpretation :
high HbA1c levels
18/08/2021
RADIOLOGY
X RAY THORAX EXAMINATION
(December 21th 2021 at 12:17 PM)
DESCRIPTION :
 Pulmo:
• The vascular pattern increases symmetrically
• Thickening on the right and left perihilar
• Diaphragm at the level of the posterior 10 th-11th rib
• The right and left costophrenic sinus in normal state
 COR
• normal shape and normal position
• Elongation of aorta

INTERPRETATION :
•Cor : Elongation of aorta
•Pulmo : Bronchopneumonia image
 03
ABNORMAL DATA
 History Taking
1. History of DM
2. Wet Cough,sometimes cough with greyish sputum
3. Wet cough 1 month ago, History of same illness (+) in
2020
4. Tingling sensation on both feet
 Physical Examination
1. tactile fremitus ( / +)
2. Bronchial breathing sound ( / +)
3. wet Ronchi (+/-)
4. Tinglin sensation on both feet

LABORATORY
1. Random blood sugar test 370 mmol/L
(hyperglycemia)
2. Hba1c 8,7 %
 X Ray Thorax Examination
1. The vascular pattern increases symmetrically
2. Bronchopneumoonia Image
 04
PROBLEM LISTS
 PROBLEM LISTS
1. Type II Dibetes Melitus
2. Diabetic Neuropathy
3. Bronchopneumonia
 Assesment
Pharmacological Treatment :
Subject : Wet cough, and tingling • Acarbose 50 mgg 2x1
sensation on both feet • Vildagliptin 50mg 2x1
• Gliclazide 50mg 2x1
Object : composmentis, • Humalog Inj. 3x26 unit
TD: 135/76 mmHg, HR: 84 bpm, • Azitromycin 500 mg tab 1x1
Temp : 36.8 ⁰ C, • Acetylsteine 200 mg caps 2x1
RR : 20 bpm • OBH syr 3x1
GDS : 370 mg/dl • Gabapentin 100 mg 1 x 1
HBA1C : 8,7 • Mecobalamin 0,5 mg 3x1

Assesment : DM Type 2, Non Pharmacological Treatment :

Bronchopneumonia, Diabetic Neuropathy • healty diet
• Physical activity
Plan : • Low glucose diet
Blood sugar level target under 200
HBA1C target under <=5,4
 Type II Diabetes Mellitus
1. Assessment
Complication :
a. Acute complication :
hiperosmolar hiperglikemic non
ketotic , hipoglikemic
b. Chronic complication :
Microangiopathy :
Retinopathy, Nephropathy
Macroangiopathy :
Coronary Heart Disease,
Cerebrovascular disease,
Peripheral Arterial Disease
2. IP Dx :
HbA1c, Random blood glucose, e
3. IP Tx :
Non Pharmacological Treatment :
Balanced nutrition therapy
Low sugar diet
Pharmacological Treatment :
Acarbose 50 mgg 2x1
Vildagliptin 50mg 2x1
Gliclazide 50mg 2x1
Humalog Inj. 3x26 unit
4. IP Mx:
Random Blood Glucose, Vital sign, Clinical Patient’s
Condition
5. IP Ex :
Educate patient on:
-Follow a healthy diet (type, total, and schedule of fo
-Increase physical activity ( 150 minute/ week divide
into 5)
- complications that may arise
- SMBG (self monitoring blood glucose)
 Diabetic Neuropathy
1. Assessment Pharmacological Treatment :
Risk Factor: type I & II DM, age Gabapentin 100 mg 1 x 1
Complication : Mecobalamin 0,5 mg 3x1
Joint’s injury, charcot joint, foot ulcer & amputation IP Mx:
Blood Glucose, Vital sign, HbA1c, Lipid
IP Dx : Profiles
Microfilament test, nerve conduction
Test, EMG, Diabetic Neuropathy IP Ex :
Symptom (DNS) educate patient on
- The risk of neuropathy, the
importance of of pain management and continous
IP Tx : evaluation
-Non Pharmacological Treatment : - Regular clinical check up
Balanced nutrition therapy - Healthy diet & lifestyle
Low sugar diet
 Bronchopneumonia
1. Assessment 3.IP Tx
Etiology: Non specific  Strep. Pneumonia, Stap. Aureus, Non Pharmacological Treatment :
h. Influenza, Balanced Nutrition Therapy
Spescific  Mycobacterium TB
Pharmacological Treatment :
• Azitromycin 500 mg tab 1x1
Risk Factor: age >65 years old, smoking, immune status
• Acetylsteine 200 mg caps 2x1
Complication : sepsis, lung abscess
OBH syr 3x1
2.IP Dx :
4.IP Mx
AFP test
• Vital sign
Bacteria culture test
• Leukocyte Count
Gram Stain test
• Ronchi/crackles
X-Ray Thorax
5.IP Ex
PCR test
•Tell the patients the cause of the disease, its
transmission and its complications
•Taking the medication regularly
THANK YOU