Cbd Dr Saugi

7/28/2019 Cbd Dr Saugi

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ADVISERDR. H. M. SAUGI ABDUH, SP.PD


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PATIENTS IDENTITY


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Patient came to IGD with chief

complaint was vomitus since 1 day

ago. Patient had vomit 12 times. Shealso felt malaise, dizziness,

jaundice, subfebrile, nausea,

decrease in appetite and the colour

of urine was dranker. She felt this

complaints after she drank drug from

her first be inpatient


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Socio-economic history:

Medical expenses incurred by Jamkesmas

Familys history of disease

- The same symptomps (-)

- TB pulmo (-)

Previous history illness- TB pulmo (+)

- Hypertension (-)

Diabetes mellitus (-)

- Asma (-)- Allergy (-)


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SYSTEMIC ANAMNESIS

General : weakness

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

Head : headache (-)

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

Ears : hearing loss (-), ring (-), discharge (-)

Nose : nosebleed (-), discharge (-)

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

Throat : pain swallow(-), hoarseness (-), difficult in swallowing (-)

Neck : enlargement of the gland (-)

Chest : cough (+), sputum (-), blood (-)Cardiac : chest pain (-), palpitations (-)

Digestive : decreased appetite(+), nausea (+), vomiting (+), defecate /

micsi (+/+), urine colour is darker

Musculoskeletal : weak (+), rigid (-), back pain (-)Extremit : oedem extremit -


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PHYSICAL EXAMINATION

General Status

General : weakness

Awareness : composmentis

Vital Sign

Blood Pressure : 100/70 mmHg

Heart rate : frequ. 76x/minutes, regural ritmict, strong

amplitudo, same equality, elastic artery wall, pulsus alternans (-), pulsus defisit (-)

Breath Frequency : 24x/minutes

Temp : 36,5o C

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


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THORAX-LUNG

INSPEKSI ANTERIOR POSTERIORStatic RR : 24x/min, Hyperpigmentation (-),

spider nevi (-), atrofi M. Pectoralis (-),

Hemithoraks D=S, ICS Normal,

Diameter AP < LL

RR : 24x/min, Hiperpigmentasi (-),

spider nevi (-), Hemithoraks D=S,

ICS Normal, Diameter AP < LL

Dinamic Up and down of hemitoraks D=S,abdominothorakal breathing, (-),

muscle retraction of breathing (-),

retraction ICS (-)

Up and down of hemitoraks D=S,

abdominothorakal breathing (-),

muscle retraction of breathing (-),

retraction ICS (-)

Palpation Palpation pain (-), tumor (-),enlargement of ICS (-), Stem fremitus

S=DPalpation pain (-), tumor (-),

enlargement of ICS (-), Stem

fremitus S=D


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Percution Sinistra : redupDextra : upper : redup; lower : sonor

Sinistra : redup

Dextra : upper : redup; lower :

sonor

Auskultati

on ronchi (+) S>D, wheezing (-) ronchi (+), S>D wheezing (-)

Interpretation: ronki +,

percussion redup infiltrat

on both lung (S>D)


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CARDIAC

Inspection Ictus cordis isnt seen

Palpation Ictus cordis is palpable in ICS V 2 cm medial from linea mid

clavicula sinistra, thrill (-), pulsus epigastrium (-), pulsuspara-sternal (-), sternal lift (-)

Percussion Upper borderline : ICS II linea sternalis sinistra

Waist : ICS III linea parasternalis sinistra

Lower right borderline : ICS V linea sternalis dextra

Lower left borderline : ICS V 2 cm medial linea midclavicula

sinistra

Auscultation Aorta valve : S1 & S2 standart, additional sound (-), AIM2

Interpretation: normal


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INSPEKSI

Symetric, sycatric(-), striae(-), scuama(-) enlargement of vena (-), hyperpigmentasi

(-), spider nevi (-)PALPATION

peristaltic (+) Normal (24 x/ minutes)

PERCUTION

side of deaf (-), shiftingdullness (-), undulation(-)

Hepar : deaf(+), liver span dextra 7 cm, liver span

sinistra 5 cm

Lien : traube space perkusi dull sound

AUSKULTATION

Superfisial :

massa (-), abdominal pain (-)

Deeper:

abdominal pain (+), hypocondrium dextra andepygastriumhepar is not palpable, lien is not palpable, kidneyis not palpable.

Interpretation: There are a process in

hypocondrium and epygastrium


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EXTREMITY

11

Ekstremity Superior InferiorOedem -/- -/-

Cold akral -/- -/-

Fisiologis reflect +/+ +/+

Interpretation: normal


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16 May

2012

19 May

2012

Normal value

Hematologi

- Hemoglobin- Hematokrit- Leukosit-

Trombosit

14,4

45,4

10,9

529

11,7-15,5 g/dL

33-45%

3,6-11 ribu/uL

150-440 ribu/uL

Kimia

- Bilirubin total- Bilirubin direk- Bilirubin

indirek- SGOT- SGPT

15,57

11,27

4,3

53

180

9,71

7,33

2,38

31

95

0,1-1,0

0-0,2

0-0,75

0-35

0-35

Imunoserologi

- HBsAg kualitatif Negative Negative


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BTA sputumSewaktu I (+) 2

Pagi (+) 2

Sewaktu 2 (+) 2


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18

Interpretasi :

normal


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INTERPRETATION

Interpretation: Cor : CPR


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Vomitus, nausea

Malaise, dizziness Subfebrile

Jaundice

Decrease in appetite

Colour of urine isdranker

Anamnesa

Weakness

Icteric sclera

Percussion lung : redupS>D

Ronchi (+) both of lungS>D

Abdominal pain(hypocondrium dexand epygastrium)

Physicalexamination

Hiperbilirubinemia

Increase liver enzym

TB pulmo

X-photo thorax :cloudiness both of lung

S>D; calsification hiluslymp

Advance

examination


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PROBLEM LIST

Hyperbilirubinemia with

jaundiceTB pulmo

Dyspepsia

HYPERBILIRUBINEMIA


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HYPERBILIRUBINEMIA

WITH JAUNDICE

Ass :

o Intrahepatic (viral hepatitis, hepatitis drug induced) or post hepatic(kolesistitis, kolelithiasis, pankreatitis, pankreas cancer)

Ip. Dx :

o Imunoserology viral hepatitis; liver function test; amylase serum,

ptotrombin time post giving vit K; USG Ip. Tx :

Therapy based on the etiology

Ip. Mx :

Bilirubin concentration, jaundice, liver function test Ip. Ex :

o Explain the cause of her complaint

o Bed rest

o Drink drug regularly


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Ip. Mx

Bilirubin serum, alanin and aspartat aminotransferase

concentration, albumin serum, fosfatase alkali

concentration

Ip. Ex :

Explain about her disease

Stop this firs inpatient drug if she gets complaints like

them and consuls to the doctor

Improvement of food and beverage hygieni

Improvement of environmental


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TBC

Ass Ip. Dx:

Ip. TxOATs First Category.

Ip. MxBTA sputum, Chest X-Ray


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IP Ex

Explain about his diseaseDrink Drugs regularlyExplain side effect of drugsThe way of transmission close the mouth when

get cough, where put the pleghm, and keep infamily condition.

Increase the good lifestyleSTOP smoking

Open the window and warm the bed on under shiningsun day regularly

Control to doctor regularly


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DYSPEPSIA

Ass :

Organic or functional dyspepsia

Ip. Dx :

Endoscopy, abdomen USG

Ip. Tx :

Inj. Pantoprazole 1A/day

Po : antacyd liquid 3x1C

Ip. Mx :

The complaint

Ip. Ex :

Avoid spicy and sour food

Avoid stress

Eating on time


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