Case Based

Disscusion

Advisor : dr. H.M. Saugi Abduh, Sp.PD

By : Diana Anggraini
Asmaraputri 30101206758

PATIENTS IDENTITY

Name : Ny. MT
Age: 77 years old
Sex : Male
Religion : Moslem
Adress : Kudu RT 02/01 Genuk Semarang
No.RM : 01.07.97.43
Room : B. Izzah 1 (407.2)
Entry Date : Juny 7th, 2016
Date Out : Juny 10th, 2016

ANAMNESA

MAIN
PROBLEM

ABDOMINAL PAIN

ANAMNESA

History
Taking

Patients
come
to
the
Emergency
Room
Islamic
Hospital of Sultan Agungs with
complains of abdominal pain
since four days ago on regio
hipocondriaca dextra, without
nausea and vomitting. Patient
didnt complain dypsneu. The
patient had never treated
previously. The patient also
complain fever, weakness and
abdominal swell since four
days ago, the temperature was
38.5C.

History of Illness
History of previous illness
Same symptom/illness

Familys history of disease

Hypertension history (-)
DM history (-)
Hepatitis history (-)
Alchohol history (-)

(+)
Hypertension history (-)
DM history (-)
Hepatitis history (+)
Smoking history (-)
Alchohol history (-)
Alergy history (-)
Sosio-Economic
History :
Cardiac Disease
(-)
Drug allergy (-) Hospital cost certified by JKN PBI
Economic Impression : enough

Vital Sign
7/6

8/6

9/6

10/6

BP

120/70
mm/Hg

110/90
mm/Hg

90/50
mm/Hg

100/60
mm/Hg

HR

88x/minute

90x/minute

64x/minute

80x/minute

RR

24x/minute

20x/minute

24x/minute

18x/minute

38,5C

36,0C

36,5C

36,3C

Systemic Medical History Taking

General
: dyspneu (-), weakness (+), fever (+)
Skin
:itching(-),jaundice(-),pale(-), slick (-)
Head
:headache (-)
Eyes
:blurredvision(-), red eyes(-),conjungtiva
anemic (+/+), ictericsclera(-/-)
Ears
:discharge(-), hearingloss(-)
Nose
:nosebleed(-),discharge (-)
Mouth
: cyanosis(-), thrush(-),bleeding gums(-)
Throat
:painswallow(-), hoarseness(-), difficult in
swallowing(-)
Neck
: trakhea deviation (-), Lymph Hypertropy
(-),enlargement ofthe gland(-)
Chest
: cough(-),sputum(-),blood(-)

Cardiac
:chest pain(-),palpitations(-)
Digestive
:abdominal pain (+), acites (+),
diarrhea(-), decrease appetite (+), nausea(-),
vomiting(-), defecate/micsi (-/-)
Musculoskeletal : weak(-),rigid(-),back
pain (-)
Extremity
: oedem of lower extremity (+),
Oedem of upper extremity (-)

Physical Examination
General
Awareness

: weakness
: composmentis

Vital Sign

BP =
Pulse
RR =
T
=

120/70 mmHg
= 88x/menit
24x/menit
38.5 0C

Status Present

Sex
Age
Weight
Height
BMI

:
:
:
:
:

Male
77 y.o
50 kg
156 cm
20 (normoweight)

general

weakness

skin

ikterik (-)

head

Normochepal

eyes

red eye (-), conjunctiva anemis (+/+),

sclera icteric (-/-), exoftalmus (-)

ear

discharge (-)

nose

epistaxis (-), discharge(-)

mouth

sianosis (-) ,bleeding gums (-), stomatitis

(-), pain swallow (-), pharinx hiperemis (-)

neck

Thyroid enlargement (-)

cardiovascular Palpitation (-)

respiratory

Dyspneu (-)

gastrointestin
al

Abdominal pain (+), nausea (-), vomiting

(-), diarrhea (-), Abdominal discomfort
(+), acites (+), lost appetite (+)

muskuloskelet Weakness (-) , atrofi (-), tremors (-),

al
edema extremity (-)
central

(-)

Chest Examination-Lung
EXAMINATION

ANTERIOR

POSTERIOR

Inspeksi

RR : 24x/min, thoracal
breathing,Hyperpigme
ntasi (-), spider nevi
(-), atrofi M. Pectoralis
(-), Hemithoraks D=S,
ICS Normal, Diameter
AP < LL

RR : 24x/min, thoracal
breathing,
Hiperpigmentasi (-),
spider nevi (-),
Hemithoraks D=S, ICS
Normal, Diameter AP <
LL

Dinamic

Up and down of
hemitoraks D=S
,muscle retraction of
breathing (-),
retraction ICS (-)

Up and down of
hemitoraks D=S,
muscle retraction of
breathing (-),
retraction ICS (-)

Palpation

Palpation pain (-),

mass (-), Sterm
fremitus D=S

Palpation pain (-),

mass (-), Sterm
fremitus D=S

Sonor (+)

Sonor (+)

Static

Percution
Auskultation

Vesicular (+),
Vesicular (+),
Whezzing (-), Ronchi (-) Whezzing (-), Ronchi (-)

THORAX - COR

INSPECTION
Ictus cordis can be seen
PALPATION
Ictus cordis is palpable at ICS VI, linea midclavicula sinistra,
thrill (-), pulsus epigastrium (-), pulsus parasternal (-), sternal
lift (-)
PERCUTION
Upper borderline
Waist
Lower right
borderline
Lower left
borderline

:
:
:
:

ICS
ICS
ICS
ICS

II line sternal sinistra

III line parasternal sinistra
V line sternal dextra
VI linea midclavicula sinistra

AUSCULTATION
Aortic valve: S1 & S2 normal, additional sound (-), A1<A2
Pulmonal valve

: S1 & S2 normal, additional

sound (-), P1<P2

Tricuspidal valve : S1 & S2 normal, additional sound (-), T1>T2
Mitral valve

sound (-), M1>M2

: S1 & S2 normal, additional

Abdomen
1.Inspection
2. Auskultasi
3. Percussion
4. Palpation

Simetrics, sycatric(-), striae(-), enlargement of

vena (-), caput medusa (-), spider nevi (-), swell
(-)
peristaltic (-), aorta abdominal bruit (-), A.
Lienalis, A. femoralis (-)
Shifting dullness(+), undulation test (+), hepar
dullness (-) liver span dextra 6 cm, liver span
sinistra 4 cm, troub space (-)
mass (-), pain (+) , hepatomegali (-), hepar,
kidney arent palpable & lien palpable,
Splenomegali (+),Murphys sign (-)

Interpretation: ASCITES, SPLENOMEGALI

Extremities
Ekstremities superior
inferior
- Oedem
-/+/+
- Akral dingin
-/-/- Reflek fisiologis +/+
+/+
- Reflek patologis -/-/- Ikterik
-/-/Interpretation : Oedem Tungkai

LABORATORY
TEST

HEMATOLOGI
07/6/2016
Hb

9.4g/dl (L)

HT

28.0 % (L)

Trombosit

62 ribu/uL (L)

Leukosit

4.85 ribu/uL

Interpretation :
Anemia,
Trombositopeni,
Hipoalbumin

KIMIA

07/6/2016

Ureum

34 mg/dl

Creatini 0.88 mg/dl

n
Albumin 2.19 g/dl (L)
SGOT

70 U/I (H)

SGPT

26 U/I

IMUNOSERO
LOGI

07/6/2016

HBsAg
Kualitatif

Non Reaktif

KIMIA

07/6/2016

Bilirubin
Total
Bilirubin
Direct

3.22 mg/dl
(H)
1.55 mg/dl
(H)

Bilirubin
Indirect

1.67 mg/dl
(H)

Interpretasi :
Hiperbilirubinemi
a

KIMIA

08/6/2016

Albumin

2.02 g/dl (L)

KIMIA

09/6/2016

Albumin

2.23 g/dl (L)

Hipoalbumin

ECG

Interpretation
Irama : sinus
Regularitas : reguler
Axis : normo axis
Zona transisi : V3
Frekuensi : 1500/22 = 68 x/menit
Gelombang P : 0,1 mv, 0, 08 S
Interval PR : 0,12 S
Kompleks QRS : 0,08 S
Segmen ST : ST elevasi/depresi (-)/(-)
Gelombang T : tidak ada T Inverted

Interpretasi :
NORMAL

X-RAY

Interpretation

Cor: Apex
bergeser ke
laterocaudal,
Suspec
Kardiomegali
(LVH)
CTR : tidak
dapat dinilai
Diafragma
kanan setinggi
costa 7
posterior

USG

Interpreta
tion
Gambaran

sirosis hepatis
dengan
splenomegali
dan asites
Tak
tampak
tanda-tanda
Hipertensi
Porta
Cholesistolithi
asis
uk.
Diameter
sekitar
0.91

Data
Abnormality
Anamnesis :

1.Anamnesis
Abdominal:
1. Abdominal
pain
pain
2. Fever
2. Fever
3. Abdominal
3.swell/Acite
Abdominal
swell/Acite
s
s
4. Decrease
4.appetite
Decrease
appetite
5. Abdominal
5.discomfort
Abdominal Physic Examination :
discomfort
6. Weekness

7. Conjungtiva
anemic
8. Oedem of lower
extremity
9. Cor : Cardiomegali

Abdomen :
11. Acites
12. Splenomegali

Advance Examination:
Lab:
Hematologi
13. Anemia
14. Hipoalbumin
15. Trombositopeni
16. Hiperbilirubinemia
X-Ray 17. Suspect LVH
18. Diafragma kanan
setinggi costa 7
posterior
19. Apex bergeser ke
Laterocaudal
USG 20. Sirosis
hepatis
21. Spelomegali
22. Acites
23. Cholesistolithiasis

PROBLEM LIST
1. Sirosis Hepatis (1,
4, 5, 6, 16, 20)
2. Asites (2, 3, 5, 6, 11,
14, 22)
3. Cholesistolithiasis
(1, 5, 23)
4. Anemia (6, 7, 13)
5. Hipoalbumin
6. Trombositopenia

SIROSIS HEPATIS
Ass:

Kompensata

Dekompensata
IP Dx:

Endoscopy (EGD)

IP Tx:
1. Farmakologis :
- Curcuma 2x1

2. Non farmakologis :
- Bedrest

Calory diet

- Protein diet

 Ip Mx:
- rasio Albumin/Globulin
- SGOT/SGPT
- Bilrubin total
- Bilirubin direct
- Bilirubin Indirect
Ip Ex :
- Mild exercise
- Decreas in using of hepatotoxic drug (OAINS)

ASITES
Peritonitis Bakterialis Spontan, CHF,
Infection,
Transudat/eksudat
Ass

Ip Dx : Parasintesis Diagnostic (Kultur bakteri)

Rivalta test
Ip Tx :
Non Farmakology:
- Sodium & Fluid `restriction
- Bedrest
Farmakology
:
- Spironolacton 100 mg
1x1
- Furosemid 40 mg 2x1
- Propanolol 10 mg 3x1

Ip Mx :
- Albumin
- Natrium Serum
- Abdomen Circumference
Ip Ex :
- Sodium diet (6-8gr/day)
- Fluid restriction (1000 ml/day)
- Decreas in using of hepatotoxic drug (OAINS)

Cholesistolithiasis
Ass
:
Cholesistitis
Cholangitis
IP Dx
:
Alkali fosfatase
Gamma GT
Amylase serum
Ip Tx

: Ursodeoxycholic acid 250mg 3x1

IpMx
: USG
IpEx :
- Bedrest
- fat restriction
- high intake of vegetables and fruit

Anemia
Ass
: normokrom normositer
hipokrom mikrositer
IP Dx
:

blood test (Eritrosit)

peripheral blood smear
MCH
MCV
MCHC
retikulosit tes
Fe/TIBC

Ip Tx
: SF 300mg 3x1 tab
vit c 1x 1
IpMx
: Blood test (E, Hb, Ht, Leukosit, Trombosit)
IpEx : Meat consumption

Hipoalbumin
Ass

:-

IP Dx
Ip Tx

:: Albumin 25% dalam 100ml 2x1

IpMx

IpEx

: Correction of albumin
Albumin serum
: - Sodium diet (6-8gr/day)
- Fluid restriction (1000 ml/day)

Trombositopeni
Ass

: DIC

IP Dx : APPT
Ip Tx : IpMx : Trombosit serum
Hemoragic sign
IpEx : -

THANK YOU