CASE BASED

DISCUSSION
Advisor :
Dr. dr. Hj. NUR ANNA CHALIMAH SA’DIYAH, Sp.PD, K-EMD,
FINASIM

By :
Talitha HelgaSafira
30101607744
KEPANITERAAN KLINIK ILMU PENYAKIT DALAM
RUMAH SAKIT ISLAM SULTAN AGUNG SEMARANG
Patient’s Identity

Name : Mr.S
Age : 62 years old
Gender : Male
Religion : Islam
Occupation : Retired Civil Servant
Address : Genuk, Semarang
MR Number : 01090xxx
Room : Endocrine clinic
Examination Date : 20th September 2021
ANAMNESIS
 History Taking

Main History of Present

Complaint Illness
Numbness in the lower A 62 year old man came to Sultan Agung
Islamic Hospital with complaints of numbness
extremities on his finger legs since 3 days ago accompanied
by vomiting. The patient also knew that he has
Diabetes Mellitus since 5 years ago.
 History of Illness

History of previous Illness Family’s history of disease Socio-economic history

Same Illness (+) Heart disease history (-)

Hospital cost covered by
Hypertension history (-) DM history (+)
“BPJS non-PBI class I”
DM history (+) Hypertension history (-)
Heart disease history (-) Asthma history (-)
Asthma history (-)
Alergy history (-)
Smoking (-)
Alcohol (-)
CAD history (-)
CKD history (-)
 Physical
Examination
 VITAL SIGN BMI
General condition : Composmentis
Awareness : E4M6V5 (GCS
15) Weight : 70 kg
Blood Pressure : 120/72 mmHg High : 159 cm
Heart Rate : 85 bpm BMI : 27,7 Kg/m2
Respiration Rate : 20 bpm Abdominal circumference : 102 cm
Temperature : 36.5 C
SpO2 : 100%
Random blood sugar test : 259 mg/dL

Hyperglycemia Overweight
Nutritional Status Based On Who In Asian
 General Physical Examination

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

• Head : headache (-)
• Eyes : blurred vision (-), conjunctival anemic (-), conjunctival icterus
(-)
• Ears : hearing loss (-), discharge (-)
Interpretation :
• Nose : nosebleed (-), discharge (-)
Normal
• Mouth : cyanosis (-), thrush (-)
• Throat : odynophagia (-), hoarseness (-), dysphagia(-)
• Neck : tracheal deviation (-), lymphoid hypertrophy (-), JVP (normal)
Chest : cough (-), sputum (-), Blood (-)
Cardiac : chest pain (-), palpitations (-)
Digestive : abdominal pain (-), epigastric pain (-) nausea vomiting (-), cicatrix (-)
Musculoskeletal : weakness (-), rigidity (-), back pain (-), edema(-), crepitation (-)

Interpretation: Normal
 Thorax Examination (Lung)
EXAMINATION ANTERIOR POSTERIOR
Inspection – Static RR : 20x/min RR : 20x/min
Thoracoabdominal breathing Thoracoabdominal breathing
Spider nevi (-) Spider nevi (-)
Atrophy of Pectoral muscle (-) Atrophy of Pectoral muscle (-)
Hemithorax D=S Hemithorax D=S
ICS Normal ICS Normal
Diameter AP < LL Diameter AP < LL

Inspection – Dynamic 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 (-), tactile fremitus Tenderness (-), Mass (-), tactile
(N) fremitus (N)

Percussion Sonor Sonor

Auscultation Vesicular (+), Ronchi (-), Wheezing (-), Vesicular (+), Ronchi (-), wheezing
(-),

Interpretation : Normal
 Thorax Examination (Cardiac)
INSPECTION Ictus cordis invisible
PALPATION thrill (-), parasternal impulse(-), sternal lift (-), epigastric pulsation(-)
PERCUSSION • Upper borderline of heart : ICS II left sternal line
• Waist of heart : ICS III left parasternal line
• Lower right borderline of heart : ICS V right sternal line
•Lower left borderline of heart : ICS V, 2cm medial from left midclavicular line
AUSCULTATION
• Aortic 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
 Abdominal Examination
INSPECTION symetric, distention (-), sycatric (-), striae (-), enlargement of vein
(-), caput medusae (-), hiperpigmetation (-), edema (-)
AUSCULTATION Peristaltic (+), abdominal aorta bruits (-), splenic artery (-) femoral
artery (-)
PERCUSSION Tympanic, shifting dullness (-), Undulation test (-), Liver dullness (-),
• Liver : Liver span (-), hepatomegaly (-)
• Spleen : Splenomegaly (-)Traube space percussion  tympani
PALPATION • Superfisial : mass (-), epigastric pain (-),
• Profundal : epigastric pain (-), liver normal, spleen and kidney
were not palpable,
• Murphy’s sign (-)
• Rovsing sign (-)

Interpretation : Normal
 EXTREMITY
SUPERIOR INFERIOR

Edema -/- -/-

Cold -/- -/-

Warm -/- -/-

Fluctuation -/- -/-

Pain -/- -/- INTERPRETATION :

NUMBNESS IN LOWER
Numbness -/- +/+ EXTREMITIES

Absces/ Ulcer -/- -/-

Pathological Reflex -/- -/-

Physiological Reflex +/+ +/+

 Additional
examination
 LABORATORY EXAMINATION
Pemeriksaan Hasil Nilai Normal

Kimia Klinik

Fasting blood glucose 117 (H) 70-110 mg/dL

LDL Cholesterol 147 (H) 60-130 mg/dL

Trigliserid 130 <160 mg/dL

Interpretation: Hyperglycemia, hypercholesterolemia

Abnormality
Data
 Abnormality Data

History Taking: Physical Examination:

- Numbness on finger of Laboratory Examination:
lower extremity.
 BMI: overweight  Hyperglycemia
- Diabetes Mellitus history  Abdominal  Hypercholesterolemia

circumference : 102 cm

Problem List:
1. Type 2 DM
2. Diabetic Neuropathy
3. Metabolic Syndrom
 Problem List

01 Type 2 DM

02 Diabetic Neuropathy

03 Metabolic Syndrome
Assessment
 Type 2 DM
Assessement Prognosis :
DD :  Ad vitam : bonam
Type 1 DM, Diabetes Insipidus  Ad sanationam : bonam
Suggesed for treatment  Ad fungsionam : bonam
Pharmacological Treatment
 Humalog kwikpen inj. 3x20 IU SC Premeal Complication:
 Metformin 500 mg 2x1 postmeal afternoon and night • ACUTE :
Non Pharmacological Treatment : • Hypoglycemia
• Hyperglycemia
 Balanced nutrition therapy
• CHRONIC :
 Low sugar diet
• Microangiopathy
 Lifestyle modification • Diabetic Neuropathy
Education : • Diabetic Retinopathy
 Healthy diet (type, total, and schedule of food) • Diabetic Nephropathy
 Aerobic or physical activity • Macroangiopathy
 Regular SMBG ( Self Monitoring Blood Glucose) • Coronary Heart disease
 Early detection of diabetic releted complications • Peripheral Arterial disease
Planning • Cerebrovascular disease
Suggesed supporting examination : • Status glicemic
• RHbA1C
• Funduscopy
• ECG
• BGA test
 Diabetic Neuropathy
Assessment :
Risk Factor: type I & II DM, age
Suggesed for treatment :
Pharmacological Treatment
 Gabapentin 300 mg 1 x 1, at night
 Tramadol 50 mg 2 x 1, if needed
Non Pharmacological Treatment :
 Balanced nutrition therapy
 Low sugar diet
Education :
 Explain the risk of neuropathy, the importance of
pain management and reguraly evaluation
 Regular clinical check up
 Healthy diet & lifestyle
Planning
Suggesed supporting examination :
 Microfilament test
 Nerve conduction test
 EMG
 Diabetic Neuropathy Symptom (DNS)

Prognosis :
 Ad vitam : bonam
 Ad sanationam : bonam
 Ad fungsionam : bonam
 Metabolic Syndrome
Education
• Proper medication
Assessment • Lifestyle modification (3-4 days/week
History of DM, Hypertension exercise, low salt and sugar diet)
and Dyslipidemia • Healthy diet (type, total, and schedule
of food)
Suggesed of treatment Planning
Non Pharmacological Treatment : Suggesed supporting examination :
- Low salt and sugar diet  Fasting blood glucose
- Low fat diet, high protein and fiber diet  Lipid profile
- Balanced nutrition therapy  ECG
- Reduce stress Prognosis :
Pharmacological Treatment :  Ad vitam : bonam
Metformin Tab 500 mg 3x1  Ad sanationam : bonam
Simvastatin tab 10 mg 1x1 Ad fungsionam : bonam
Complication :
 Microvascular
 Macrovascular
 Ateroschlerosis
‫َم ا َأْن َز َل ُهللا َد اًء ِإاَّل َأْن َز َل َلُه ِش َفاًء‬
"God does not bring down disease
unless He also lowers its antidote." (HR Bukhari).
Thankyou!
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 QUESTIONS FROM DR ANNA

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 QUESTIONS FROM P.18.1

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 QUESTIONS FROM P.18.2

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