CASE PRESENTATION

Mrs. H/43 yo

PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat/ RSUD dr. H.M. Ansari Saleh
 Identity

• Name/Age : Mrs. H/ 43 y.o

• Birth of date : 05 February 1980
• Medical Record : RMK 01489498
• Occupation : House Wife
• Marital status : Married
• Last Education : Senior High School
• Adresses : Jl. Sungai Andai
 Anamnesis

Identity : Mrs.H /43 y.o

Chief complaint : Abdominal Pain
HISTORY OF PRESENT ILLNESS :
• The patient came with complaints of abdominal pain, specially in epigastric and
umbilical since 3 days before entering the hospital, suddenly after eating rice which is rather
hard and fatty. Abdominal pain felt continuously and penetrates to the back, but not
radiated or spread to neck, shoulder, or legs. Complaints of pain such as being stabbed
more often in the middle of the night thus disturbing sleep. Complaints of pain increase
when eating foods and do not change with position, pain is reduced when patient didn’t take
any food.
• 3 days ago the patient went to the emergency room because of same complaints accompanied
with nausea and vomiting 1-2 times and contains of water and little amount of food. Patient
felt better after got treated, then went home with medicine, but the complaint reappear, and
nausea vomiting got worsened, patient vomiting more than 10 times when visit the
hospital for the second time, feeling weak and had decreased of appetite.
• Defecation 2-3 times a day, consistency was soft, yellow color, mucus (-), blood (-)/black
stools (-). Urinate 3-4 times a day about 1 cup per times, dark yellow color. Pain while
 Anamnesis

• History of consumption of pain medication and herbal medicine was denied.

• Complaints of fever (-), cough (+), shortness of breath (-), and weight loss (-)
• Tired quickly because of activities (-), wake up at night because of shortness of breath (-),
patient can lay down without pillow or just one pillow.
• For couple of year, patients often experience complaints of heartburn and nausea, but they go
away on their own or are reduced by taking medicine from the pharmacy.
• History of Pulmonary TB 20 years ago, patient completed the treatment for 6 months, and
was diagnosed clear by doctor that time.
• History of Hypertension, DM and jaundice was denied.
 Anamnesis
HISTORY OF PAST ILLNESS
Pulmonary TB (+), Liver disease (-), heart disease (-), kidney disease (-), malignancy (-).
HISTORY OF PAST MEDICATION
Gastric medicine (forget the name)
FAMILY MEDICAL HISTORY
No other family members experience the same abdominal pain symptoms like the patient does.
HT (-), DM (-), Kidney Disease (-), Heart Disease (-)
PERSONAL AND SOCIAL HISTORY
• The patient is a housewife
• The patient didn’t have history of consuming alcohol
• The patient wasn’t a smoker
• History of drug abuse or herbal medicine was denied
 Physical Examination
Tokyo guidelines 2018  acute cholecystitis : not met entry criteria
Weight : 48 kg
General appearance: looked moderate ill Height : 155 cm  Acute cholangitis : not met entry criteria
GCS : E4V5M6 IMT : 20 (normoweight)
Alvarado score 4 (unlikely appendicitis)
VAS : 5
BP: 126/69 mmHg HR: 134 bpm RR: 20 bpm Tax: 37.4oC SpO2 : 96% on RA
Eye : Pale conjunctiva (+), sclera icteric (-), palpebra oedema (-), moon face (-)
Head Mouth : Pale (-), cyanosis (-), dry mucosa (-), ulcer (-)
Tongue : Papilla atrophy (-)
Etc : Atrophy M. Temporalis (-), hair loss (-)
JVP : R+1 cm H2O, hepatojugular reflux (-)
Neck Lymph node : Lymph node enlargement (-)
Thyroid : Symmetrical (+/+), enlargement (-/-), pain (-/-)
Axilla : Lymph node enlargement (-)

Inspection : Ictus cordis not seen

Palpation : Ictus palpable at ICS V midclavicula line sinistra, thrill (-)
Percussion : LMH (Left Margin of Heart) ictus cordis at ICS V midclavicula line sinistra
: RHM (Right Margin of Heart) : sternalis line dextra
Thorax Heart
Auscultation ✔ ICS II Parasternalis line dextra: aortic valve murmur (-)
✔ ICS II Parasternalis line sinistra: pulmonal valve murmur (-)
✔ ICS IV-V Parasternalis line sinistra: tricuspid valve murmur (-)
✔ ICS IV-V midclavicularis line sinistra: mitral valve murmur (-)
 Physical Examination

Inspection: symmetrical thoracal expansion, intercostal retraction (-)

Vocal Fremitus Percussion Breath Sound Ronchi Wheezing Egophony

D=S Sonor Sonor vesicular vesicular - - - - - -

D<S Sonor Dull vesicular Vesicular ↓ - - - - - -

Thorax Lung
(Anterior) D<S Sonor Dull vesicular Vesicular ↓ - - - - - -

D<S Sonor Dull vesicular Vesicular ↓ - - - - - -

D<S Sonor Dull vesicular Vesicular ↓ - - - - - -

D<S Sonor Dull vesicular Vesicular ↓ - - - - - -

 Physical Examination
Inspection: symmetrical thoracal expansion, intercostal retraction (-)

Vocal Fremitus Percussion Breath Sound Ronchi Wheezing Egophony

D=S sonor sonor vesicular vesicular - - - - - -

D=S sonor sonor vesicular vesicular - - - - - -

D<S sonor Dull vesicular Vesicular ↓ - - - - - -

Lung
Thorax (Posterior)
D<S sonor Dull vesicular Vesicular ↓ - - - - - -

D<S sonor Dull vesicular Vesicular ↓ - - - - - -

D<S sonor Dull vesicular Vesicular ↓ - - - - - -

D<S sonor Dull vesicular Vesicular ↓ - - - - - -

 Physical Examination
Inspection : Flat (+), venectation (-), protrude umbilicus (-), no pulsation was seen.
Auscultation : Bowel sounds (+) 10x/minute, other sounds (-)
Percussion : tympanic sound Inferior border of right rib --> dullness (liver)
Inferior border of left rib -> tympani (gastric)
Traube space timpani
Palpation : Abdominal tenderness (+) a/r epigastrium and umbilical
Defensive muscular (-)
Murphy's sign (-)
Superficial mass (-)
Abdomen Intra-abdominal mass (-)
The patient's face doesn’t look painful when the abdomen is palpated
Blast (-)
Free fluid examination : Shifting dullness (-)
Liver palpation : not palpable
Palpation of the spleen : not palpable
Palpation of McBurney's point: Tenderness (-), pain relief (-), Local muscular defans (-)
Ballotement : Impression was not felt on right/left
CVA tap pain : Right (-/-) left (-/-)
Inguinal Lymphadenopathy (-)
Spoon nails (-/-), clubbing fingers (-/-), petechiae (-)
Edema superior (-/-),Oedema inferior ext. (-/-), pitting edema (-)
Extremity CRT < 2”
Enlarged lymph nodes (-/-), flapping tremor (-), palmar erythema (-)
Clinical Manifestation
 Laboratory Results
Lab 11/11/23 Normal
Lab 11/11/23 Normal
Haemoglobin 9.8 12.0 – 16.0
Basophyl% 0.5 0.0 – 1.0
Leukocyte 9.63 4.8 – 10.8
Eosinophyl
0.4 2.0 – 4.0
Erythrocyte 3.61 4.00 – 5.00
%
Neutrophyl 77.1 46.0 – 73.0
Haematocrit 30.5 36.0 – 48.0 %

Platelet 547 150 – 400 Limphocyte 11.2 17.0 – 48.0

%
RDW-CV 13.3 11.0 – 16.0
Monocyte % 10.8 2.0 – 8.0
MCV 84.5 75.0 – 100.0

MCH 27.1 25.0 – 35.0

MCHC 32.1 31.0 – 37.0

 Laboratory Results
Lab 11/11/23 Normal

RBG 121 <200

SGOT 10 10 – 37

SGPT 22 12 - 40

Ureum 46.8 15-45

Creatinine 0.8 0.7 – 1.2

 Laboratory Results
Urinalysis
Lab 11/11/23 Value Lab 11/11/23 Value
Macroscopic Sediment
Color Yellow Yellow Leucocyte 1-2 2–4
Clarity Clear Clear Erythrocyte 0-1 0–1
Specific gravity 1.015 1.005 – 1.030 Epithel 3-5 8 - 15
pH 5.0 5.0 – 9.0 Crystal Negative negative
Keton Negative negative Cylinder Negative negative
Protein Albumin 1+ negative Bacteria 10-15 negative

Glucose Negative negative Others Negative negative

Bilirubin Negative negative

Occult blood Negative negative
Nitrit Negative negative
Urobilinogen Normal Normal
Leucocyte Esterase Negative negative
ECG (11/11/2023)
 ECG Interpretations 12/04/2023

Sinus Tachycardia Q wave : pathological Q (-)

Regular QRS Complex : 0.08 s, RBBB -, LBBB -

Heart Rate 110 bpm ST segment : isoelectric, ST elevation (-), ST depression (-)

Frontal Axis normoaxis T inverted (-), peak tall T (-), U wave (-)

Horizontal Axis: no rotation

R/S <1
R V5/6 + S V1 <35 RVH (-), LVH (-)
P wave : 0.08 s, P mitral (-), P pulmonal (-)

Conclusion :
PR interval : 0.12 s
Sinus Tachycardia 110 bpm
 Chest X-ray (12/04/2023)
Identity Mrs.H / 43 yo
Position AP
Density Enough
Inspiration Enough
Soft Tisse Normal
Bone Intact
Trachea In the middle
Hilus D/S Normal
Mediatinum Wide
Cor hard to evaluate
Hemidiapragha Sinistra (massive fibrotic process)
Dextra (normal)

Costophrenicus Sinistra : hard to evaluate

Sinus Dextra : sharp

Parenchym Infiltrat (-)

Conclusion Expertise (-)
massive fibrotic process left hemithorax
Infiltrate (-)
 TIMELINE

couple years 3 days before

Admission day
ago admission

• History of • Abdominal • Came to ER

Epigastric pain with
pain and • Nausea abdominal
Nausea pain
• Vomiting
profuse
 RESUME OF DATABASE
ANAMNESIS PHYSICAL EXAMINATION OTHER EXAMINATION

• Abdominal pain (+) Objective

KU: looks moderate ill
Scoring Laboratorium 11/11/23 ECG 11/11/23
Summary
Tokyo of 2018
guidelines Database
 acute Hb 9.8 Sinus tachycardia, 110 x/m
• Nausea (+) GCS: E4V5M6 cholecystitis : not met entry criteria
MCV 84,5
MCH 27.1
BP: 126/69 mmHg
• Vomit (+) HR: 134 bpm  Acute cholangitis : not met entry Leu 9.630
N% 77.1
CXR 11/11/23
Massive fibrotic process left
criteria
• Decrease of appetite RR: 20 bpm
Tax: 37.4oC Alvarado score 4 (unlikely
L% 11.2
Trombosit 547.000
hemithorax
Infiltrat (-)
(+) SpO2 : 96% on RA appendicitis) GDS 121
Ureum 46.8
Weight : 48 kg
• Soft stool Height : 155 cm
Cr 0.8
SGOT 10
IMT : 20.0 (normoweight) SGPT 22
VAS : 5 Urinalisis 11/11/23
Warna kuning jernih
BJ 1.015
Head/neck : pale conjunctiva (+), icteric PH 5.0
sclera (-), JVP R+1 cmH20 , enlarged Keton (-)
Prot-albumin (+)
lymphatic (-) Glukosa (-)
Pulmo: ves (VVV/V<<), rh (---/---), wh Bilirubin (-)
Darah samar (-)
(---/- --) Nitrit (-)
Cor: BJ 1-2 single, murmur (-), gallop (-) Urobilinogen N
Abdomen: Distended (-), BS (+), soefl, Bakteri 10-15
tenderness (+) a/r epigastium + umbilical
Extremities: , warm (+/+), edema inferior
-/-, CRT <2 s,

PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat/ RSUD Ulin Banjarmasin
 PROBLEM LIST

1. Abdominal pain + Nausea vomitus

2. Massive fibrotic left hemithorax
3. Anemia NN

PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat/ RSUD Ulin Banjarmasin
 INITIAL PLAN

Planning Planning Planning

CUE AND CLUE Problem List Initial Diagnosis
Diagnosis Therapy monitoring

Mrs. H/ 43 yo 1. Abdominal pain 1.1 Peptic Ulcer - Benzidin test Non Pharmacology Planning Monitoring
- complaints of abdominal pain since 3 days before + Nausea vomitus disease - OMD Soft diet, 1400 kcal/day - Subjective : pain, nausea-
entering the hospital 1.2 Gastritis - Endoscopy vomitus severity
- Abdominal pain felt continuously and penetrates to 1.3 GERD - VS : temp, VAS
the back, but not radiated or spread to neck, Pharmacology - CBC
shoulder, or legs Inj omeprazole 2x1
- pain increase when eating foods inj ondansentron 3x4mg Planning Education
- Defecation 2-3 times a day, consistency was soft, po sukralfat 4x2c - Educate about the condition,
yellow color, mucus (-), blood (-)/black stools (-) po rebamipide 3x1 suspected etiology, and
inj antrain 3x1 amp (if needed) management
Physical Examination: Laboratory Findings: - Explain that the condition still
VAS 5 Laboratorium 11/11/23
Hb 9.8 needed to be diagnosed first
HR 110 before able to be definitely
MCV 84,5
MCH 27.1 treated
Physical Examination : - Avoid triggering food : fatty,
Leu 9.630
Epigastric tenderness (+) N% 77.1 sour, spicy
L% 11.2
Scoring Trombosit 547.000
Tokyo guidelines 2018  Ureum 46.8
acute cholecystitis : not
met entry criteria
 Acute cholangitis : not
met entry criteria
Alvarado score 4 (unlikely
appendicitis)
 INITIAL PLAN

Planning Planning Planning

CUE AND CLUE Problem List Initial Diagnosis
Diagnosis Therapy monitoring

Mrs. H/ 43 yo 2. Severe 2.1 GI loss Non Pharmacology Planning Monitoring

- Nausea and vomitus 3 days ago. Went to ER 3 days hypokalemia - High potassium diet - Motoric strength
ago and was advised to be admitted, but refused the (improved) 2.2 Low intake - Serum potassium evaluation
advice Pharmacology - ECG changes
- Given KSR 2x600 mg as to be taken at home IVFD Asering 1500 cc/24 hours
- Decrease of appetite (+) 3 days due to nausea and Planning Education
vomiting - Eat food high in potassium

Physical Examination: Laboratory Findings:

Motoric strength
5/5 Lab 12/04/23
5/5 K 3.2

Lab 07/04/23
K 2.5

ECG (12/04/23)
Sinus rhythm, 90 bpm,
U wave (-)
 INITIAL PLAN

Planning Planning
CUE AND CLUE Problem List Initial Diagnosis Planning Diagnosis
Therapy monitoring

Mrs. H/ 43 yo 3. HF stage B FC II 3.1 HHD NTproBNP Non Pharmacology Planning Monitoring :

- Getting tired quickly during activities (+) since2 • Life style modification • Subjective : DoE, othopneu,
years ago 3.2 IHD Echocardiography • Low salt < 5 gram/day PND
- Sleeping using two pillows, or waking up at night • Echocardiography evaluation
because of shortness of breath were denied Pharmacology
- Hypertension since 10 years ago Lisinopril 1x5 mg Planning Education
• Educate patient about life
style modification  adjust
daily activity, exercise as
Physical Examination: Laboratory Findings: tolerated, BW reduction,
JVP 5+2 cm H20 healthy diet, and control the
Extremity : edema -/- ECG (12/04/23) BP
Sinus rhythm, 90 bpm
Framingharm Criteria:
Mayor : Cardiomegaly CXR (12/04/23)
Minor : DoE Cardiomegaly (+)
 Progress Note
No Date Time SOAP Resident On Duty Supervisor
(Internist)
1 13/04/2023 06.00 Subjective: dr. Diah
Objective: GCS E4V5M6 Sukmawati, SpPD
BP: mmHg
HR : x/minute
RR : x/minute, kusmaul (+)
T:C
SpO2 % Urine Output :
Assessment:
Epigastric pain + nausea-vomitus +
jaundice + elevated liver enzyme +
hyperbilirubinemia direct dominant +
Therapy :
 Progress Note
No Date Time SOAP Resident On Duty Supervisor
(Internist)
2 13/04/2023 06.00 Subjective: dr. Diah
Objective: GCS E4V5M6 Sukmawati, SpPD
BP: mmHg
HR : x/minute
RR : x/minute, kusmaul (+)
T:C
SpO2 % Urine Output :
Assessment:
Mild hypokalemia
Therapy :
 Progress Note
No Date Time SOAP Resident On Duty Supervisor
(Internist)
3 13/04/2023 06.00 Subjective: dr. Diah
Objective: GCS E4V5M6 Sukmawati, SpPD
BP: mmHg
HR : x/minute
RR : x/minute, kusmaul (+)
T:C
SpO2 % Urine Output :
Assessment:
HF stage B FC II
Therapy :
 PROBLEM ANALYSIS
Mrs. H/ 43 yo
Fatty Female Flatulence Forty

Elevated liver enzyme +

Epigastric pain + Nausea
Hypertension Hyperbilirubinemia dominant
vomitus
direct + Murphy sign

Low intake Extrahepatic intrahepatic

GI loss

Fatty liver
HF stg B FC II Hypokalemia Cholelithiasis Cholangitis Cholecystitis disease
 THANK YOU

PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat/ RSUD Ulin Banjarmasin