CASE BASED DISSCUSION

RIFQI ALI ZAKI

(01.208.5765)

ADVISOR
dr. Erwin Budi Cahyono, Sp. PD
PATIENT IDENTITY
Name : Mrs. N

Age : 70 years old

Gender : Female
Religion : Moslem
Address : Semarang
Room : Baitul Izzah
Check in date : 17 August 2012

Check out date : 21 August 2012

 HISTORY TAKING

• Pasien datang datang dari IGD dengan keadaan lemas, badan gemetar, keringat
dingin, berkunangkunang seperti mau pingsan. Pasien juga mengeluhkan
badannya sakit semua.

History of previous illness

• Hypertension (-)
• Liver disease (-)
• Kidney disease (-)
• Diabetes mellitus (+)

Family history of disease (-)

Social economic history

• Free clinic
 Systemic Anamnesis
General : edema(-)
Skin : itching (-), jaundice (-), pale (-)
Head : headache (+)
Eyes : blurred vision (-), red eyes (-), jaundice sclera (-/-)
Ears : hearing loss (-), discharge (-)
Nose : nosebleed (-), discharge (-)
Mouth : cyanosis (-)
Throat : pain swallow (-), hoarseness (-), difficult in swallowing (-)
Neck : trachea deviation (-), lymph hypertrophy (-)
Chest : dyspnea (-), cough (-), sputum (-), blood (-)
Cardiac : chest pain (-), palpitations (-)
Digestive : nausea (-), vomiting (-), defecate / miction (+/+)
Muscular : stiff neck (-), back pain (-)
Extremity : edema of lower extremity (-), edema of upper extremity (-)
 PHYSICAL EXAMINATION
General • weak
Awareness • Somnolen
Nutrient state • Weight = 45 kg; Height = 150 cm
BMI • 45 / (1,5)² = 20 (normoweight)
• TD 120/80 mmHg
• HR 90/menit
Vital Sign
• RR 24 X/m
• T 36,5 C
Head • Mesocephal, alopesia (-)
Eyes • Anemic Conjuntival (+/+), Jaundice Sclera(-/-)
Nose • Secret (-), Nostril Breath (-)
Ears • Normal Shape, Discharge (-/-)
Throat • Hyperemic (-), Pain Devour (-)
Mouth • Cyanosis (-), Dry Lips (-),
Neck • Trachea Deviation (-), Lymph Hypertrophy (-)
Extremity • edema of lower extremity (-)
 THORAX - PULMONARY
INSPEKSI ANTERIOR
Static RR : 24x/min, Hiperpigmentation
(-), spider nevi (-), atrofi M.
Pectoralis (-), Hemithoraks S=D,
ICS extend (-), Diameter AP < LL
Dinamic Up and down of hemitoraks
S=D, muscle retraction of
breathing (-), retraction ICS (-)
Palpation Palpation pain (-), tumor (-),
enlargement of ICS (-), Stem
fremitus D=S
Percution Sonor
Auskultation Vesicular(+), ronchi (-),
wheezing (-)
POSTERIOR
RR : 24 x/min, Hiperpigmentation
(-), spider nevi (-), Hemithoraks
Hemithoraks S=D, ICS extend (-),
Diameter AP < LL
Up and down of hemitoraks S=D,
muscle retraction of breathing (-),
retraction ICS (-)
Palpation pain (-), tumor (-),
enlargement of ICS (-), Stem
fremitus D=S
Sonor
Vesicular(+), ronchi (-), wheezing
(-)
 THORAX - COR
• Inspection : Ictus cordis isn’t seen.
• Palpation : Ictus cordis is palpable in ICS V linea mid clavicula sinistra,
thrill (-).
• Percussion : hiposonor (dull) sound
• Upper borderline of heart : ICS II linea sternalis sinistra
• Waist of heart : ICS II linea parasternalis sinistra
• Lower right borderline of heart : ICS V linea parasternalis dextra
• Lower left borderline of heart : ICS V mid clavicula sinistra
• Auscultation :
• Aorta Valve : SD I-II pure, regular, AI<A2
• Trikuspid Valve : SD I-II pure, regular, T1>T2
• Pulmonal Valve : SD I-II pure, regular, P1<P2
• Mitral Valve : SD I-II pure, regular, M1>M2
• Addition Sound : (-)

Interpretation : Normal
 ABDOMEN
• Inspection : flat(+), cycatric(-), striae(-), caput medusa (-
).
• Auscultation : peristaltic (+) N
• Percution : dull (+), shifting dullness (-)
• Palpation
• Superficial : massa (-)
• Deeper : abdominal pain (-), hepar, lien isn’t palpable,
renal isn’t palpable

Interpretation: Normal
 Extremities

Extremities superior inferior

- edema -/- -/-
- cold -/- -/-
- reflect physiologist +/+ +/+
- Icteric -/- -/-
 LABORATORY

06/07/2012
Haemoglobin 11.1 g/dl
Ht 35.1 %
Leukocyte 7.5 3/uL
Platelet 4273/uL
Random blood 35 mg/dl
glucose

Hipoglikemia
ECG
1. Rhythm : Regular
2. Heart Rate : 1500/18 = 83 x/m
3. Axis : NAD (Normo Axis Deviation)
4. Transitional Zone : V3
5. Morphology :
- P wave : Normal (0,04 second)
- Interval PR : Normal (0,12 second)
- QRS complex : Normal (0,08 second)
- ST segment : elevation (-) depression (-)
- T wave : Inverted (-) T tall (-)

Interpretation : NSR
 Abnormal Data
Advance
Anamnesis : Examination:
Physic Examination :
• Lemah, lemas
• Berkunangkun •Somnolen -Lab:
Hipoglikemia
ang
• Seperti mau
pingsan
• Riwayat DM
+
 PROBLEM LIST
1. HIPOGLIKEMIA AKUT
 HIPOGLIKEMIA AKUT
ASSESMENT Ringan , Sedang, Berat

IP DX GDS, GDP, GD2PP, tes fungsi ginjal, tes fungsi hati

IP TX - Glukosa Oral 10-20 gr/150-200ml minuman yang
mengandung glukosa
- Glukagon i.m. 1mg
- Glukosa i.v. 75-100 ml glukosa 20%
IP MX -Pantau GDS
-Pertahankan GD 200 mg/dL
IP EX - Edukasi pengobatan DM yg disesuaikan dengan waktu,
makanan, pengaruh aktivitas jasmani, tanda2
hipoglikemi dini, penanganan awal hipoglikemi
 FOLLOW UP
17/8/2012 18/8/12 19/8/12 20/8/2012 21/8/12

BP 120/80 110/90 120/90 100/70 120/60

HR 88 x/m 80 x/m 72 80 76

RR 24 x/m 20 x/m 20 20 20

t 36,5 36,2 36,3 36,5 36,5

GDS 38 144 176 200 230

THANK YOU