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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:
Akhmad Ulil Albab
01.210.6076

Pembimbing:
dr. Lusito, Sp.PD

BAGIAN ILMU PENYAKIT DALAM


FAKULTAS KEDOKTERAN UNIVERSITAS ISLAM SULTAN AGUNG
SEMARANG
2015
CASE REPORT

A. Patient`s Identity
 Name : Mrs. S
 Age : 55 y.o
 Sex : Female
 Religion : Moslem
 Job : Swasta
 No. Medical Record : 01.24.8057
 Address : Banjar Sari 02/05 Sayung, Demak
 Room Care : Baitul Izzah 1
 Date in : March, 5th 2015
 Date out : March, 8th 2015
 Status Care : JKN Non PBI

B. Data
1. Anamnesis
 Main Problem : abdominal pain on the upper right region
o History of Present Illness
Patient come to the emergency room complaining her abdominal pain. The pain
was appear both on the change of the body’s position into the right or left side. She
also said that her stomach was getting bigger time by time since 4 months ago and
more progressive at this late week. The patient also complain that she usually feel
filled-with-air sensation on her stomach and nausea but she was not complain
vomiting. Three days before she goes to the hospital, she still complain the nausea
and decreasing of the appetite. And one day before she goes to the hospital she
complain that her abdominal pain was so heavier, nausea, and the size of her
stomach is getting bigger. There are no history of cigarette and alcohol
consumption on this patient.

o History of previous illness


 Hypertension history (-)
 Heart disease history (-)
 DM history (-)
 Maag (+)
 Hepatitis (+)
o Family’s history of disease
 Hypertension history (-)
 DM history (-)
o Sosio-Economic History :
 Hospital cost certified by JKN NON PBI

C. Systemic Anamnesis
o General : dyspneu (-), 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 in swallowing (-)
o Neck : enlargement of the gland (-), nape pain (-)
o Chest : cough (-), sputum (-), blood (-)
o Cardiac : chest pain (-)
o Digestive : abdominal pain (+) at the upper right region, decreased
appetite (+), nausea (+), vomiting (-), defecate/micsi (+/+)
o Musculosceletal : weak (-), rigid (-), back pain (-)
o Extremity : oedem inferior extremity (-)

D. Physical Examinations
General Status
◦ General : Dypsneu (-)
◦ Awareness : composmentis
◦ Head : Mesocephal, alopesia (-)
◦ Eyes : Anemic Conjuntiva(-/-), Icteric sclera(+/+)
◦ Nose : symmetric, secret (-), Nostril Breath (-)
◦ Ears : Normal Shape, discharge (-/-)
◦ Esophagus : Hyperemic (-), pain devour (-)
◦ Mouth : Cyanosis (-), dry lips (-)
◦ Neck : Trakhea deviation (-), Lymph Hypertropy (-)
◦ Extremity : Oedem of lower and upper extremity (-)

Vital Sign
o Blood Pressure : 100/70 mmHg
o Heart rate : freq. 74 x/minutes
o Breath Frequency : 18x/minutes
o Temp : 36,2o C

a. PF thorax
Pulmo:

INSPEKSI ANTERIOR POSTERIOR

Static RR : 18x/min, Hyperpigmentation (-),


Hyperpigmentation (-), tumor (- tumor (-), inflammation (-),
), inflammation (-), spider nevi (- spider nevi (-), Hemithorax
), Hemithorax D=S, SIC D=S, SIC Normal, Diameter
Normal, Diameter AP < LL AP < LL

Dinamic hemithorax movement D=S hemithorax movement D=S

Palpation Palpation pain (-), tumor (-), Palpation pain (-), tumor (-),
normal ICS enlargemnet of ICS normal ICS, Stem fremitus
(-), Stem fremitus D=S D=S

Percussion Dextra: sonor Dextra : sonor


Sinistra : sonor Sinistra : sonor

Auscultation Decrease of vesicular sound (-) Decrease of vesicular sound


ronchi (-/-), wheezing (-/-) (-)
ronchi (-/-), wheezing (-/-)
Cor :
• Inspection : Ictus cordis isn’t seen.
• Palpation : Ictus cordis is palpable at SIC VI 2 cm linea mid clavicula sinistra,
thrill (-), pulsus epigastrium (-), pulsus para-sternal (-), sternal lift (-
).
• Percussion : dull sound
 Upper borderline of heart : SIC II linea sternalis sinistra
 Waist of heart : SIC IV linea parasternalis sinistra
 Lower right borderline of heart : SIC IV linea sternalis dextra
 Lower left borderline of heart : SIC V linea mid clavicula sinistra
• Auscultation
 Aorta valve : S1 & S2 standart, additional sound (-), AI < A2
 Pulmonal valve : S1 & S2 standart, additional sound (-), P1 < P2
 Trikuspidal valve : S1 & S2 standart, additional sound (-), T1 > T2
 Mitral valve : S1 & S2 standart, additional sound (-), M1 > M2

b. Abdomen
 Inspection : convex of surface(+), sycatric(-), striae(+), enlargement of vena (-),
caput medusa (-)
 Auscultation : peristaltic (+)
 Palpation
 Superfisial : supel, massa (-)
 Deeper : abdominal pain (+), hepar palpable (+), lien aren’t palpable,
Murphy’s sign (-)
 Percussion : tympany, side of deaf (+), shifting dullness (+)
 Hepar : deaf (+), liver span dextra 14 cm, liver span sinistra 8 cm
 Lien : troube space percussion (+)  tympani
c. Extremities
Extremity superior inferior
- Oedem -/- -/-
- cold extremities -/- -/-
- Physiological reflex +/+ +/+
- Icteric -/- -/-
Laboratory`s Examination
HEMATOLOGY
 Hemoglobin : 9,1 g/dl
 Hematokrit : 28,0%
 Leukosit : 6,4 ribu/uL
 Trombosit : 218 ribu/ uL

CHEMISTRY
 GDS : 85 mg/dl
 SGOT : 157 U/l
 SGPT : 52 U/l

IMUNOSEROLOGI
HbsAg Kualitatif Reaktif
ECG

Kesan:
Normo sinus rhytm
USG Abdomen

Kesan:
 Hepatomegali + nodul dan asites masif  keganasan di hepar curiga hepatoma
 Organ-organ intra abdomen lainnya pada USG masih dalam batas normal
E. Data of Abnormality
Anamnesis:
• Abdominal pain on the upper right regio
• Nausea
• Weak
• The size of the abdomen that getting bigger day by day
• The history of hepatitis
Physical Examination :
 abdominal pain when palpate on the upper right region
 hepatomegaly
 side of deaf (+), shifting dullness (+)
Advance Examination:
• Anemia
• sign of the abnormality of liver function
• HBsAg reactive
• USG abdomen
Kesan: hepatomegaly + nodul dan asites massif  keganasan hepar curiga
hepatoma
Problem List
1. Sirosis Hepatis
2. Hepatitis B kronik

F. Discussion
1. Sirosis Hepatis
Ass : (etiology)
Hepatitis Virus B
Hepato Cellular Carcinoma
Alkoholik
IP Dx : Px lab: HbeAg, HbvDNA, alfa-fetoprotein, liver biopsy/ peritoneoskopi
IP Tx :
Liver transplantation
IP Mx : vital sign, icteric progression
IP Ex :
Tell about patient’s illness both to the patient or patient’s family, the etiology
of the disease, and explaining the goals of therapy.

2. Hepatitis B Kronik
Ass : (complication)
Sirosis Hepatis
Hepato Cellular Carcinoma
Varises Esofagus
IP Dx : endoscopy  gastroscopy, alfa-fetoprotein, HbvDNA
IP Tx :
pharmacology
salbutamol 2 mg 3x1
ceftriaxone 1 x 2 gr
OBH syr. 3x1

IP Mx : vital sign, patient’s complain


IP Ex :
Tell about patient’s illness both to the patient or patient’s family, the etiology
of the disease, and explaining the goals of therapy.

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