CBD

Case Based Discussion

Advisor : dr. H. M. Saugi Abduh, Sp.PD, KKV, FINASIM
By: Dian Fitri S (30101507425)
Patient Identity
Name : Mrs. R
Age : 60 years old
Gender : Female
Religion : Moeslem
Job : Unemploye
Address : Loireng rt 03/2 Sayung Demak
MR Number : 01274183
Room : Baitulizzah 1/C2
Entry Date : 2 Desember th, 2019
HISTORY TAKING
MAIN PROBLEM HISTORY OF PRESENT
Dyspnea ILNESS
Patient came to the emergency room of Sultan Agung Hospital
Semarang with complaints of dyspnea. The complaint has
been felt for 20 years if exposed to dust, cold, fatigue, and
stress, but the last 1 year has never relapsed. 3 days ago the
patient complained of dyspnea and coughing. These
complaints appear after the patient eats mangoes. Dyspnea
getting worse when doing activities and at night, decreases if
the patient sits bent. The patient's cough with sputum viscous.
The patient has a history of asthma, DM, hypertension and
penicillin drug allergy.
 Sistemic Anamnesis
Patient Complain Main Complains: Dyspnea
Dyspnea
Onset: 3 day before came to Hospital

Location: -

Quality and Quantity: Dyspea is felt disappear and arise at night

Chronology: 1 day before the patient was

hospitalized the patient ate mango and the
tightness was getting heavier.
Modification factor: dyspnea is exacerbated when doing
activities and at night, is reduced if the patient sits bent

Comorbid complains: the patient complained of cough

 History of Illness
History of previous illnessFamily History Socio Economic History
 Hypertension  Hypertension (+)
Hospital cost certified by
(+)  DM (+)
“BPJS-NON PBI”
 DM (+)  CHF (-)
 CHF (-)  CKD (-)
 CKD (-)  Stroke (-)
 Stroke  Allergic (+)
(-) mother dermatitis atopi
 Allergic (+)  Same Symptomp(-)
 Uric Acid (-)
 Same Symptomp (-
)
Physical Examination
 GENERAL STATUS
 General condition : look short
of breath
 Awarness : Composmentis/
E4V5M6

 Vital Sign
o BP : 176/94 mmHg
o HR : 112 x/minute
o RR : 28 x/ minute
o Temp : 36 0C
Interpretation
Hypertention, Tachycardi
 • Mesocephal
Anemic conjuntiva (-/-) • (+)
Icteric sclera (-/-) • • Alopesia (-)

Symmetric • • Normal
Secret (-) • shape
Nostril Breath (-) • • Discharge (-
• /-)
Skin jaundice (-)
Cyanosis (-) • • Pale (-)
dry lips (-) • • Hiperpigmentasi (-
snoring (-) • )

Tracheal deviation (-) • • Oedem extremity

Lymph hypertrophy (-) • inferior (-/-)
Increasing JVP (-) • • Numbness in limb (-/-)
• Sianosis (-)
• Cold extremities (-)
Interpretation:
Normal
 Intrerpretation:
Lung Examination Retraction of muscle
breathing wheezing
Dextra Sinistra

Inspection RR : 28x/min, Hyper pigment (-), spider nevi (-), atrophy Pectoral Muscle (- RR : 28x/min, Hyper pigment (-), spider nevi
Static
), Hemithoraks S=D, ICS Wider, Diameter AP < LL barrel chest (-) (-), atrophy Pectoral Muscle (-), Hemithoraks S=D, ICS Wider, Diameter AP < LL
barrel chest (-)

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

Palpation Palpable pain(-), tumor (-), Arcus costae angle < 900, wider of ICS (-), alpable pain(-), tumor (-), Arcus costae angle < 900, wider of ICS (-), Chest
Chest Expantion simetris, Stem fremitus S=D Expantion simetris, Stem fremitus S=D

Percusion Sonor (+) Sonor (+)

Auscultation Vesikuler (+) Vesikuler(+)

wheezing (+) Wheezing (+)
Ronchi (-) Ronchi (-)
 Cardiac Examination Intrerpretation:
Cardiomegaly
Inspeksi Ictus cordis isn’t seen

Palpation
thrill (-), epigastric pulse (-), parasternal pulse (-), sternal lift (-).
Percussion - Upper borderline of heart : ICS II left sternal line
- Waist of heart : ICS III left parasternal line
- Lower right borderline of heart : ICS IV right sternal line
- Lower left borderline of heart :ICS V from left midclavicula line 1cm shift to
lateral
Auscultation
Aorta valve : S1 & S2 Pulmonary valve : S1
standart, additional & S2 standart,
sound (-) additional sound (-)

Tricuspid valve : S1 & Mitral valve : S1 & S2

S2 standart, standart, additional
additional sound (-) sound (-)
 Abdominal Examination
Inspeksi Bulging(-), Hyperpigmentation (-), Sycatric(-), Striae(-), Vein Distention (-), Caput Medusa (-)

Auscultation Peristaltic (+) Normal ( 8 x / minute )

• Hypertimpani (-), side of deaf (-), shifting dullness (-)

Percussion • Liver : dullness (-)
• Spleen : Traube space percussion (Timpani)

• Superfisial : tight (-), mass (-), epigastrial pain (-)

Palpation
• Deep : abdominal pain (-), liver (-) and spleen palpable (-) renal (-) Murphy’s sign (-)

Intrerpretation:
Normal
Laboratorium
 Hematology
Des, 2th 2019
Hematology Result Normal

Hemoglobin 11,2 L 11,7 – 15,5 g/dl

Hematokrit 35,5 33 – 45 %

Leukosit 9,60 3,6 – 10,6 Ribu/uL

Trombosit 352 150 – 440 Ribu/uL

Golongan Darah A / Positif - Intrerpretation:

Anemia
Blood glucose Result Normal Hyperglikemia
GDS 313 H 90-199 mg/dl
 Kimia DES, 2th 2019

Kimia Result Normal

Ureum 21 10 – 50 mg/dl
Intrerpretation:
Blood Creatinin 1,03 0,7 – 1,3 mg/dl hyponatremi
Hiperchloremia
Natrium 134,9 L 135 – 147 mmol/L

Kalium 4,03 3,5 – 5,5 mmol/L

Chloride 106,7 H 95 – 105 mmol/L

ECG
Interpretation :sinus tachycardi
 Interpretation
• Rhytm : sinus
• Regularitas : reguler
• Frekuensi : 115x/menit
• Axis : NAD (LI +, aVf +)
• Zona Transisi :-
• Gelombang P : 0.08 dtk (normal)
• Interval PR : 0.12 (normal)
• Komplek QRS : 0.8 (normal)
• Gelombang Q : normal
• Segmen ST : normal
• Gelombang T : normal Interpretasi: Sinus Tachycardi
 Interpretation :
Cor : apeks ke laterocaudal
Pulmo : corakan bronkovaskuler
meningkat tampak bercak di
kedua lapang paru
Diagfregma dan sinus
costophrenicus kanan kiri baik

KESAN:
1. Cardiomegaly (LV)
2. Gambaran bronkitis
 Abnormality Data
History
Taking
1. Dyspneu Laboratori
2. Chough with um
sputum 10. Hyperglikemi
3. Allergy 11. Anemia
4. History of asthma 12.Hypercloremia

Physical
13.Hyponatremi
Egc:
Examination 14. Sinus
5.Wheezing tachycardi
6. Muscle retraction of
breathing X ray:
7.Hypertention
8. Tachycardi 15.
9. Tachipneu
Cardiome
galy
16.
 PROBLEM LIST

01 ASTHMA BRONKIAL

02 TYPE II DM

03 HIPERTENTION HEART DISEAS

04
04 BRONKITIS
Asma bronkial
 Assesment:  IpMx :
- DD :
- PPOK
- Bronkitis kronik
• General Status
- Congestif Heart Failure •Kesadaran
- Obstruktif mekanis • Vital sign (BP, HR, RR)
- Emboli paru
 IP Dx :
• Lung physiology examination  IpEx :
(spirometer)
• Uji reversibilitas (dengan
bronkodilator) • Bed rest
• Bronchial provocation test • If there is a recurrence, use
• Allergy test (skin prick test)
• Foto thorax prescription medications and
 Ip Tx : controllers
- O2 Nasal Canul 3 liter/minute
- Nebulaizer : ventolin +pulmocort / 8 jam • Recognize and Avoid triggers
- Inj. Metilprednisolon 6,25mg/ 8 jam / allergens
- OBH syr 3x1
- Salbutamol tab 3x2 mg
• Regular control
TYPE II DM
 Assesment:

• Glycemic status  Ip Tx :
• Mikroangiopati: • Humalog 3x/10 unit
retinopaty diabetic
nefropaty diabetic
Neuropaty diabetic
• Makroangiopati:
 IpMx :
diabetes foot
Peripheral Arterial Disease •Vital sign
Cerebral Vascular Disease •Glycemic status
Coronary Heart Disease

 IP Dx :
• GDP, GD2P  IpEx :
• HbA1c •Eat proper diet(3 J)
• Funduskopi
• Microalbumin Test
•Take medicine regularly
• EMG •Active on daily activity
• Arteriography •Hygene personal
• CT Scan
• Angiography
• Lipid Profile (LDL, HDL)
• Ureum Creatinin
Hypertension heart disease
 Assesment:
 Ip. Mx :
Hipertension Benigna - Vitl sign

Hipertension Maligna  Ip. Ex :

 IP Dx :
-Funduskophy  Diet low salt
Stay away from stress
-Echocardiography Increase mild exercise
Routinely taking medication
 Ip Tx : Routinely check of blood pressure
- Non Farmakologi
Low salt intake
- Farmakologi
Amlodipine 2x10 mg PO
Captopril 2x12,5 mg PO
BRONKITIS  IP Dx :
- x foto thorax posisi AP
 Assesment:
-Pemeriksaan mikrobiologi
 Etiologi: -Biasan bronkus/ sputum
•Bronkitis akut rhinovirus, respiratory -Darah rutin
 Ip Tx
sincytial virus (RSV), virus influenza,
Oksigenasi dengan nasal kanul
coxsakie virus
•Bronkitis kronis  asthma,
Infus RL+ Drip aminofilin 20 tpm

chronic respiratory infections Nebulaizer (combivent+pulmicot perbandingan

Faktor Resiko 1:1)
Allergy OBH syr 3x1
Weather change  Ip. Mx :
- Vitl sign
Air pollution
Chronic upper respiratory tract infection  Ip. Ex :
Encourage the patient to lie on a high pillow
•Kegawatan
Take medication regularly
Apneu
Recurrent infections
Thank You!
Any questions?