CASE BASED DISCUSSION

Diajukan untuk
Memenuhi Tugas Kepaniteraan Klinik dan Melengkapi Salah Satu Syarat Menempuh
Program Pendidikan Profesi Dokter Bagian Ilmu Penyakit Dalam
Di Rumah Sakit Islam Sultan Agung Semarang

Disusun oleh:
Dzikril Hakim
01.211.6373
Pembimbing:
dr. Lusito, Sp.PD

BAGIAN ILMU PENYAKIT DALAM

FAKULTAS KEDOKTERANUNIVERSITAS ISLAM SULTAN AGUNG
SEMARANG
2015

CASE REPORT
A. Patient`s Identity
Name

: Mr. S

Age

: 58 years old

Gender

: Male

Religion

: Islam

Job

: Farmer

Address

: Mojodemak, Demak

MR number

: 01263541

Room

: Baitul izzah 1

Check in date

: 9/9/2015

Check Out date

: 12/9/2015

B. Data
1. Anamnesis
Main Problem : Abdominal Pain
o History of Present Illness
Patient came to RSISA on 9 September 2015 with abdominal pain in upper left
abdomen since 1 week ago. He also complain about nausea and vomiting. The
abdominal pain appear everytime but in last 4 days the complain more painful. The
complain better if resting and worsening when he doing activity. He ever go to doctor
but the complain still remaining.

o History of previous illness

Hypertention (-)
DM (-)
Alcohol (-)
Maag (+)
Hepatitis (-)
Smoking (+)

o Familys history of disease

Hypertention (-)
DM (-)
Maag (-)
Hepatitis (-)

o Sosio-Economic History :

Hospital cost certified by GENERAL

C. Systemic Anamnesis
o General

: weak

o Skin

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

o Head

: headache (-)

o Eyes

: blurred vision (-), red eyes (-), icteric sclera (-/-)

o Ears

: hearing loss (-), discharge (-)

o Nose

: nosebleed (-), discharge (-)

o Mouth

: cyanosis (-), thrush (-), bleeding gums (-)

o Throat

: pain swallow(-), hoarseness (-), difficult inswallowing (-)

o Neck

: enlargement of the gland (-), nape pain (-)

o Chest

: cough (-), sputum (-), blood (-)

o Cardiac

: chest pain (-)

o Digestive

abdominal pain (+) at the upper left

region, decreased appetite (+), nausea (+), vomiting (+),

defecate/micsi (+/+)
o Musculosceletal : weak (+), rigid (-), back pain (-)
o Extremity

: oedem inferior extremity (-)

D. Physical Examinations
General Status

General

: Weak

Awareness

: composmentis

Vital Sign

Blood Pressure

: 110/80 mmHg

Heart rate

: 70 x/minutes, reguler, adequate amplitudo, same equality,

elastic artery wall, pulsus

alternans

(-),

pulsus

defisit (-)

Breath

: 18x/minutes

Temp

: 36o C

Head : Mesocephal, alopesia (-)

Eyes

Nose : symmetric, secret (-), Nostril Breath (-)

Ears

Throat : Hyperemic (-), pain devour (-)

Mouth : Cyanosis (-), dry lips (-),

Neck : Trakhea deviation (-), Lymph Hypertropy (-)

Extremity

: Anemic Conjuntival (-/-), Icteric sclera(-/-)

: Normal Shape, discharge (-/-)

: Oedem of lower extremity (-), Oedem of upper extremity (-)

a. PF thorax
Pulmo:
INSPEKSI

ANTERIOR

POSTERIOR

Static

RR
:
18x/min,
Hyperpigmentation (-), tumor
(-), inflammation (-), spider nevi
(-), Hemithorax D=S, ICS
Normal, Diameter AP < LL

RR
:
18x/min,
Hiperpigmentasi (-), tumor
(-), inflammation (-), spider
nevi (-), Hemithorax D=S,
ICS Normal, Diameter AP <
LL

Dinamic

hemithorax movement D=S,

abdominothorakal breathing, (-),
muscle retraction of breathing
(-), retraction ICS (-)

hemithorax movement D=S,

abdominothorakal
breathing,
(-),
muscle
retraction of breathing (-),
retraction ICS (-)

Palpation

Palpation pain (-), tumor (-),

Arcus costae angle < 900,
enlargement of ICS (-), Stem
fremitus D=S

Palpation pain (-), tumor

(-), enlargement of ICS (-),
Sterm fremitus D=S

Percussion

Dextra:sonor
Sinistra : sonor

Dextra : sonor
Sinistra : sonor

Auscultatio
n

ronchi (-), wheezing (-/-)

ronchi (-), wheezing (-/-)

Cor:

Inspection
: Ictus cordis isnt seen.
Palpation
: thrill (-), epigastric pulse (-),parasternal pulse (-), sternal lift (-).
Percussion
: dull sound
Upper borderline of heart
: ICS II left sternal line
Waist of heart
: ICS III left parasternalis line
Lower right borderline of heart
: ICS V right sternal line
Lower left borderline of heart
: ICS V, 2 cm medial from left mid
clavicle line
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 (-)

b. Abdomen

Inspection

: symetric, sycatric (-),striae (-), scuama (-), enlargement of

vena (-), hiperpigmentasi (-). Spider nevi (-)

Auscultation
:peristaltic (+) Normal (20 x/ minutes)
Palpation
Superfisial
: massa (-), abdominal pain (-)
Deep
:abdominal pain (+),hepatomegali (-). splenomegali (-),

Percussion
Liver
Spleen

Murphys sign (-)

: tympani, side of deaf (-), shifting dullness (-)
: deaf(+), liver span dextra 7 cm, liver span sinistra 5 cm
:Throbe space percussion (+) tympani

c. Extremities
Extremity

superior

inferior

- Oedem

-/-

-/-

- cold extremities

-/-

-/-

- Physiological reflex

+/+

+/+

-/-

-/-

- Icteric

Laboratory`s Examination

HEMATOLOGY

Hemoglobin

Hematokrit: 48,4%

Leukosit

Trombosit : 263 ribu/ uL

: 16,7 g/dl

: 7,6 ribu/uL

CHEMISTRY

Ureum

: 22 mg/dl

Creatinin

: 0,93 mg/dl

SGOT

: 21 U/l

SGPT

: 22 U/l

Natrium

:143,4 mmol/L

Kalium

:4,40 mmol/L

Cloride

:99,1 mmol/L

IMUNOSEROLOGI
HbsAg Kualitatif

Non Reaktif

Thorac X-ray

Kesan :

Cor normal

Elongasi aorta

Pulmo normal

CT Scan Abdomen

Kesan:
Hepar, lien, ginjal, pancreas normal
E. Data of Abnormality
Anamnesis:

Abdominal pain in upper left abdomen

Nausea
Vomiting

Physical Examination:

Abdominal pain in hipocondriaca sinistra

Advance Examination:
Problem List
1. Dispepsia
F. Discussion
Dispepsia
Ass

:
Dispepsia fungsional ( tidak ada kelainan organ)
Dispepsia organik Gastritis
Tukak gaster
Tukak duodenum

IP Dx :
Endoskopi
Ip Tx :
Non Farmacology
Tirah baring
Farmacology
Inj. Pantoprazol
Paracetamol 3 x 1
Braxidin 3 x1
Ulsidex 3 x 1
IP Mx: vital sign
IP Ex:
Eat regulary
Not eat sour and spicy, coffee
Avoid cigarette
Consumption drug regularly
Bed rest