CASE BASED DISCUSSION

GALIH WIDIYANTO012095913

ADVISOR: . DR.LUSITO, SP.PD

PERIODE JUNE– AUGUST, 2014

Patient’s Identity• Name : Mr. M.I• Age : 18 y.o• Gender : Male• Religion : Moslem• Job : -• Address : Wonosowo RT 03/03 Karang

Tengah• MR number : 01.12.9077• Room : Baitul Izzah I• Entry date : July 19th, 2014• Date out : July 21th, 2014

ANAMNESA• Patient came to hospital with weakness. Body felt weak ±

3 days. In addition, patients also complain of body pale and easily tired. Also decreases appetite. The patient admitted that he had often experience complaints like this every 3 months. Patients already diagnosed with thalassemia since the age of 3 years. Since then every 3 months once the patient begins to feel the complaint and go Hospital to obtain additional blood. The patient had undergone transfusion more than 20 times. Cough (-), cold (-), shortness of breath (-), vomiting (-), bleeding (-), enlarged abdomen (-), normal bowel and bladder.

History of IllnessHistory of previous illness• Felt this illness before• Hypertension history (-)• Heart disease history (-)• DM history (+)• Gastritis (-)• Asthma history (-)• Thalasemia history (+)

Family’s history of disease• There is no family have

ilness like him• Hypertension history (-)• DM history (+)• Asthma history (-)

Social Economi History :• Hospital cost certified

by JKN PBI• Economic Impression :

less

Systematic Anamnesis General : weakSkin : itching (-), jaundice (+), pale (+), slick (-)Head : headache (-)Eyes : blurred vision (-), red eyes (-)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 (-) Dyspneau (-)Cardiac : chest pain (-), palpitation (-)Digestive : decrease apetite , nausea (+), vomiting (-), defecate / micsi (+/+) Musculoskeletal : weak (-), rigid (-), back pain (-) Extremity : oedem extremity ( -/-)

Physical Examination General Status

◦ General : weak◦ Awareness : Composmentis◦ Nutrient Status

Height = 150 cmWeight = 31 kgBMI = BB(kg)/TB²(m²)

= 31 kg/(1,50 m)²= 13,8(Underweight)

Vital Sign

o Blood Pressure : 90/70 mmHg

o Heart rate : frequ. 96 x/minutes, regural ritmict, strong amplitudo, same equality, elastic arterywall, pulsus alternans (-), pulsus defisit (-)

o Breath Frequency : 24 x/minutes

o 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 (-)

Skin : Skin turgor (+), Pale (+)

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

Thorax-LungINSPEKSI ANTERIOR POSTERIOR

Static RR : 24 x/min, Hyperpigmentation (-), spider nevi (-), atrofi M. Pectoralis (-), Hemithoraks

D=S, ICS Normal, Diameter AP < LL

RR : 24 x/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 (-), Arcus costae angle < 900, enlargemnet of ICS (-), Stem

fremitus D=S

Palpation pain (-), tumor (-), Stem fremitus D=S

Percution sonor Sonor

auscultation

Vesicular sound (+), wheezing (-), ronchi (-)

Vesicular sound (+), wheezing (-), ronchi (-)

Interpretation : normal

THORAX - CORINSPEKSIIctus cordis can’t be seen PALPATIONIctus cordis is palpable at ICS V, 2 cm medial from linea mid clavicula sinistra, thrill (-), pulsus epigastrium (-), pulsus parasternal (-), sternal lift (-)

PERCUTIONDull sound Upper borderline Waist

Lower right borderline Lower left borderline

: ICS II linea sternalis sinistra: ICS III linea parasternalis sinistra : ICS V linea sternalis dextra: ICS V, 2 cm medial from linea mid clavicula sinistra

AUSKULTATION

Aorta valve

Pulmonal valve Trikuspidal valve Mitral valve

: S1 & S2 standart, additional sound (-), AI<A2: S1 & S2 standart, additional sound (-), P1<P2: S1 & S2 standart, additional sound (-), T1>T2: S1 & S2 standart, additional sound (-), M1>M2

Interpretation : normal

ABDOMEN 1.Inspection convex of surface(+), sycatric(-), striae(-), enlargement of

vena (-), caput medusa (-)

2.Auskultasi peristaltic (15x/minutes), bising aorta abdominal, A. Lienalis, A. femoralis (-)

3. percussion tympani all abdominal surface,Liver span : dex >12cm ; sinistra > 8cm, area troube (-)

4. palpation Superfisial : supel, massa (-)Deeper : pain (-), hepatomegali (+), Spleenomegali (+)

Murphy’s sign (-)

interpretation : Hepatosplenomegali

Extremity

Ekstremity Superior Inferior

Oedem -/- -/-

Cold extremities -/- -/-

Physiological Reflect +/+ +/+

Ikteric -/- -/-

Impression normal

Laboratory Result – July 19th, 2014

Examination Result Unit Normal value

Hematology Hemoglobin 6.0 mg/dl 11,7-15,5

Hematocrit 17.8 % 33-45

Leukocyte 53.3 Thousand/uL 3,6-11,0

Platelet 684 Thousand/uL 150-440

Blood group/ Rh O/ positive

GDS 532 mg/dl 75 – 100

Imunoserology

HBsAg Non Reaktif Non Reaktif

Chemical

Interpretation :Anemia

LeukositosisTrombositosisHiperglikemi

Data AbnormalityAnamnesis

1. Weakness2. Nausea3. Decrease

appetite4. DM history5. Thalasemia

history

Physic Examination6. Sclera Icterik (+/+)7. Conjungtiva Anemis8. Skin, Pale (+)9. Hepatosplenomegali10.Underweight

Advance examination

Lab :11. Leucocytosis12. Anemia13. Trombositosis14. Hiperglikemi

Problem list

1. THALASEMIA2. HIPERGLIKEMIA3. UNDERWEIGHT

THALASEMIA

• Ass : Thalasemia MayorThalasemia Minor

• IpDx : Darah rutin, MCV,MCH,MCHC, Apusan darah tepi

• IpTx : Rehidration RL 20 tpmTranfusi PRC 4 kalf

• IpMx : Vital sign, Fluid balance, Tranfusion Reaction• IpEx : Tell about his illness

HIPERGLIKEMIA• Ass : DM Tipe 1

DM Tipe 2 • IPDx : HbA1c, Funduscopi, Microalbuminuria, Blood

Glucose, Grow and Development• IPTx :

– Inj. Insulin 20 UI• IPMx : General condition, Vital sign

lab : Blood Glucose• IPEx :

– Low glucose diet– Consumption drug regularly

KEBUTUHAN KALORI

• Kebutuhan Kalori :– BB ideal : (TB -100)x 1kg : (150-100)x1kg= 50 kg– Jenis kelamin x BB = 30 x 50 = 1500 kalori – Age : -– Activity : 10% x 1500 = 150 kalori

• 1500 + 150 = 1650 kalori

UNDERWEIGHT

• Ass : - • IPDx : BMI, Z score• IPTx : Diet Kalori, High Protein• IPMx : General condition, Vital sign, BMI• IPEx :

– Tell about the illness– Eat More kalori and protein

Follow up

19/07/2014 20/07/2014 21/07/2014

O

TD90/70 mmhg 100/80 mmhg 90/70 mmhg

HR96 x/minutes 88 x/minutes 84 x/minutes

RR24 x/ minutes 22 x/ minutes 20 x/ minutes

t36,5 36,7 36,4

Laboratory Result – July 20th, 2014

Examination Result Unit Normal value

Hematology Hemoglobin 10.4 mg/dl 11,7-15,5

Hematocrit 30.4 % 33-45

Leukocyte 43.2 Thousand/uL 3,6-11,0

Platelet 546 Thousand/uL 150-440

WASSALAMU’ALAIKUM