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  • Case Based Discussion: Oleh: Fita Diyan Erika Pembimbing: Dr. Nur Ana C, Sp. PD, KEMD, FINASIM

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    Mrs. A, a 61-year-old female, presented with a 2-month history of persistent cough with phlegm. Her medical history included hypertension and diabetes. Physical examination revealed hypertension, pre-obesity, and rhonchi on auscultation. Laboratory tests showed low-level tuberculosis, hyperglycemia, and a chest X-ray found right pleural effusion and pneumonia. She was assessed with diabetes, hypertension, and tuberculosis. Treatment plans included lifestyle modifications, anti-hypertensive medications, anti-tuberculosis treatment, and insulin therapy to control her diabetes.

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    Mrs. A, a 61-year-old female, presented with a 2-month history of persistent cough with phlegm. Her medical history included hypertension and diabetes. Physical examination revealed hypertension, pre-obesity, and rhonchi on auscultation. Laboratory tests showed low-level tuberculosis, hyperglycemia, and a chest X-ray found right pleural effusion and pneumonia. She was assessed with diabetes, hypertension, and tuberculosis. Treatment plans included lifestyle modifications, anti-hypertensive medications, anti-tuberculosis treatment, and insulin therapy to control her diabetes.

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    20 views19 pages

    Case Based Discussion: Oleh: Fita Diyan Erika Pembimbing: Dr. Nur Ana C, Sp. PD, KEMD, FINASIM

    Uploaded by

    Fita Diyan Erika
    Mrs. A, a 61-year-old female, presented with a 2-month history of persistent cough with phlegm. Her medical history included hypertension and diabetes. Physical examination revealed hypertension, pre-obesity, and rhonchi on auscultation. Laboratory tests showed low-level tuberculosis, hyperglycemia, and a chest X-ray found right pleural effusion and pneumonia. She was assessed with diabetes, hypertension, and tuberculosis. Treatment plans included lifestyle modifications, anti-hypertensive medications, anti-tuberculosis treatment, and insulin therapy to control her diabetes.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 19

    Case Based Discussion

    Oleh: Fita Diyan Erika


    Pembimbing: dr. Nur Ana C, Sp. PD, KEMD, FINASIM
    Patient’s Identity
    • Name : Mrs. A
    • Age : 61 year old
    • Gender : female
    • Religion : Moslem
    • Address : Banjardowo, Semarang
    • Occupation : Housewife
    • Room : Endocrine Clinic
    • Medical Record : 0138xxxx
    History Taking
    Main Complain
    Persistent cough

    History of Present Illness


    A 61years old woman came to the Internal Medicine clinic off
    Sultan Agung Islamic Hospital because of her a cough
    complaint, felt 2 months ago, and has not recovered. Cough
    that is felt with phlegm, cloudy, continuous, and disturbs
    sleep. There is no factor that mitigates complaints.
    History of Illness

    Family’s history of disease

    History of previous illness • Hypertension history (-)


    • DM history (+) father
    • Same symptom/illness (+) • Asthma and allergy history (-)
    • Hypertension history (+)
    • DM history (+)
    • Asthma history (-) Sosio-Economic History
    • Allergy history (-)
    • Cardiac Disease (-) • Economic Impression : enough
    • Drug allergy (-) • Covered by BPJS NON PBI
    General Physical Examination

    Date: 8 September 2020


    Awareness : compos mentis
    BMI (Body Mass Index)
    Vital sign
    BP : 172/86 mmHg Weight : 63 kg
    Pulse : 87x/minute High : 155 cm
    Temperature : 37 oC BMI : 25,8
    Respiration Rate:16x/minute
    General Status
    • Skin : itching (-), jaundice (-), pale (-).
    • Head : headache (-)
    • Eyes : blurred vision (-), Conjunctival anemic (-/-), Conjunctival Icterus (-/-)
    • Ears : hearing loss (-), discharge (-)
    • Nose : nosebleed (-), discharge (-)
    • Mouth : cyanosis (-), thrush (-)
    • Throat : pain swallow (-), hoarseness (-), difficult in swallowing (-)
    • Neck : trachea deviation (-), lymph hypertrophy (-), JVP (normal)
    • Chest : cough (+), sputum (-). Blood (-)
    • Cardiac : chest pain (-), palpitations (-)
    • Digestive : abdominal pain (-), nausea vomiting (-), cicatrix (-)
    • Musculoskeletal : weak (-), rigid (-), back pain (-)
    • Extremity : edema (-), pain (-)
    THORAX - COR
    EXAMINATION ANTERIOR POSTERIOR

    Inspection – Static RR : 20x/min RR : 20x/min


    Thoracal breathing Thoracal breathing
    Hyperpigmentation (-) Hyperpigmentation (-)
    Spider nevi (-) Spider nevi (-)
    Atrophy M. Pectoralis (-) Atrophy M. Pectoralis (-)
    Hemithorax D=S Hemithorax D=S
    ICS Normal ICS Normal
    Diameter AP < LL Diameter AP < LL

    Inspection – Up and down of hemithorax D=S Up and down of hemithorax D=S


    Dynamic Muscle retraction of breathing (-) Muscle retraction of breathing (-)
    Retraction ICS (-) Retraction ICS (-)

    Palpation Tenderness (-), Mass (-) Tenderness (-), Mass (-)


    tactile fremitus (N) tactile fremitus (N)

    Percussion Sonor (+) Sonor (+)

    Auscultation Vesicular (+), Wheezing (-), Ronchi (-) Vesicular (+), wheezing (-), Ronchi (-)
    THORAX - COR
    Interpretation = Normal

    INSPECTION Ictus cordis isn’t seen.

    PALPATION Palpable (-), pulsus parasternal (-), sternal lift (-), pulsus epigastrium(-)

    PERCUSSION • Upper borderline of heart : ICS II left sternal line


    • Waist of heart : ICS III left parasternal line
    • Lower right borderline of heart : SIC V linea sternalis dextra
    • Lower left borderline of heart : SIC V, 2cm lateral from linea mid calvicula
    sinistra
    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 (-)
    ABD
    EXAMINATION RESULTS
    OME Inspection Symmetrical, cicatrix (-), Striae (-), Vein’s enlargement (-),
    Caput medusa (-), Spider nevi (-)
    N the right inguinal area is a bump, edema (-), reddish skin
    color

    Auscultation Peristaltic (+), Abdominal aorta’s bruits (-), Splenic Artery,


    Femoral Artery (-)
    Percussion Tympanic, Shifting dullness (-) Undulation test (-), Liver
    dullness (-), Liver span (-), Traube’s space (tympanic)

    Palpation Mass (-), Pain (-), Hepatomegaly (-), Liver, Kidney & Spleen
    are normal, Splenomegaly (-)
    Murphy’s sign (-)

    Interpretation = Normal
    EXTREMITIES

    SUPERIOR INFERIOR
    Edema -/- -/-
    Cold -/- -/ -
    Warm -/- -/-
    Pain -/- -/-

    Numbness -/- -/-

    Pathological Reflex -/- -/-


    Physiological Reflex +/+ +/+

    Interpretation = Normal
    LABORATORY EXAMINATION
      Test Result Normal Baseline
    TCM TB (07/08/20) MTB Detected Low Not detected
    HBA1C (30/07/20) 7,2 % (H) <5,4
    RBG (8/9/2020) 331 mg/dL (H) 74-106 mg/dL

    Interpretation = MTB detected, Hyperglycemia


    Thorax X-Ray

    30 Juli 2020

    Bronchovascular features increase, visible consolidation


    in the field below the right lung, diaphragm and right
    costophrenic sinus is gloomy, left area is good.

    Interpretation:
    • Cor : normal shape and position
    • Pulmo: pneumonia, right pleural
    effusion.
    Abnormality Data

    History Taking Physical Examination


    • Hypertension
    Persistent cough, pleghm and
    • BMI: Pre- obesity
    cloudy.

    Laboratory Examination
    Problem List
    ● MTB Detected Low
    ● HBA1C : 7,2 % (H) Type II DM, Hypertension,
    ● RBG: 331 mg/dL (H) Tuberculosis
    DM type II
    Assessment
    Complication :
    Acute complication : hiperosmolar,
    hiperglicemic stagenon ketotic , hipoglicemic
    Microangiopathy : Retinopathy, Nephropathy
    Macroangiopathy : Coronary heart
    disease, cardiovascular disease,
    peripheral Arterial Disease

    IP Dx :
    Fasting plasma glucose, BTA test.

    IP Tx :
    -Non Pharmacological Treatment :
    Balanced nutrition therapy
    Low sugar diet

    -Pharmacological Treatment :
    Humalog 3x10 Unit
    Levofloxacin tab 500 mg 1x1
    • ASSESMENT Tuberculosis
    Etiology : IP Mx
    oBactery: • HR
    Mycobacterium TB • RR
    IP Dx :
    • Temperature
    • Pemeriksaan gram & kultur bakteri 
    • Pemeriksaan BTA  spesifik • Leukocyte Count
    • Swab PCR • Ronchi/crackles
    IP Ex
    IP Tx
    •Tell the patients the cause of the
    Non Pharmacological Treatment :
    disease, its transmission and its
    ● Healthy nutrition complications
    Pharmacological Treatment : •Taking the medication regularly
    ● OAT 1st category.
    O mankind, there has to come to you instruction from
    your Lord and healing for what is in the breasts and
    guidance and mercy for the believers. (QS. Yunus: 57)
    Thank You
    Table of Contents

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