kasus long stay di rs

1. CASE PRESENTATION
Mrs. H/43 yo
PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat/ RSUD dr. H.M. Ansari Saleh

2. • Name/Age : Mrs. H/ 43 y.o
• Birth of date : 05 February 1980
• Medical Record : RMK 01489498
• Occupation : House Wife
• Marital status : Married
• Last Education : Senior High School
• Adresses : Jl. Sungai Andai
Identity

3. Identity : Mrs.H /43 y.o
Chief complaint : Abdominal Pain
HISTORY OF PRESENT ILLNESS :
• The patient came with complaints of abdominal pain, specially in epigastric and
umbilical since 3 days before entering the hospital, suddenly after eating rice which is rather
hard and fatty. Abdominal pain felt continuously and penetrates to the back, but not
radiated or spread to neck, shoulder, or legs. Complaints of pain such as being stabbed
more often in the middle of the night thus disturbing sleep. Complaints of pain increase
when eating foods and do not change with position, pain is reduced when patient didn’t take
any food.
• 3 days ago the patient went to the emergency room because of same complaints accompanied
with nausea and vomiting 1-2 times and contains of water and little amount of food. Patient
felt better after got treated, then went home with medicine, but the complaint reappear, and
nausea vomiting got worsened, patient vomiting more than 10 times when visit the
hospital for the second time, feeling weak and had decreased of appetite.
• Defecation 2-3 times a day, consistency was soft, yellow color, mucus (-), blood (-)/black
stools (-). Urinate 3-4 times a day about 1 cup per times, dark yellow color. Pain while
Anamnesis

4. • History of consumption of pain medication and herbal medicine was denied.
• Complaints of fever (-), cough (+), shortness of breath (-), and weight loss (-)
• Tired quickly because of activities (-), wake up at night because of shortness of breath (-),
patient can lay down without pillow or just one pillow.
• For couple of year, patients often experience complaints of heartburn and nausea, but they go
away on their own or are reduced by taking medicine from the pharmacy.
• History of Pulmonary TB 20 years ago, patient completed the treatment for 6 months, and
was diagnosed clear by doctor that time.
• History of Hypertension, DM and jaundice was denied.
Anamnesis

5. HISTORY OF PAST ILLNESS
Pulmonary TB (+), Liver disease (-), heart disease (-), kidney disease (-), malignancy (-).
HISTORY OF PAST MEDICATION
Gastric medicine (forget the name)
FAMILY MEDICAL HISTORY
No other family members experience the same abdominal pain symptoms like the patient does.
HT (-), DM (-), Kidney Disease (-), Heart Disease (-)
PERSONAL AND SOCIAL HISTORY
• The patient is a housewife
• The patient didn’t have history of consuming alcohol
• The patient wasn’t a smoker
• History of drug abuse or herbal medicine was denied
Anamnesis

6. Physical Examination
General appearance: looked moderate ill
GCS : E4V5M6
Weight : 48 kg
Height : 155 cm
IMT : 20 (normoweight)
VAS : 5
Tokyo guidelines 2018  acute cholecystitis : not met entry criteria
 Acute cholangitis : not met entry criteria
Alvarado score 4 (unlikely appendicitis)
BP: 126/69 mmHg HR: 134 bpm RR: 20 bpm Tax: 37.4oC SpO2 : 96% on RA
Head
Eye
Mouth
Tongue
Etc
: Pale conjunctiva (+), sclera icteric (-), palpebra oedema (-), moon face (-)
: Pale (-), cyanosis (-), dry mucosa (-), ulcer (-)
: Papilla atrophy (-)
: Atrophy M. Temporalis (-), hair loss (-)
Neck
JVP
Lymph node
Thyroid
: R+1 cm H2O, hepatojugular reflux (-)
: Lymph node enlargement (-)
: Symmetrical (+/+), enlargement (-/-), pain (-/-)
Axilla : Lymph node enlargement (-)
Thorax Heart
Inspection
Palpation
Percussion
Auscultation
: Ictus cordis not seen
: Ictus palpable at ICS V midclavicula line sinistra, thrill (-)
: LMH (Left Margin of Heart) ictus cordis at ICS V midclavicula line sinistra
: RHM (Right Margin of Heart) : sternalis line dextra
✔ ICS II Parasternalis line dextra: aortic valve murmur (-)
✔ ICS II Parasternalis line sinistra: pulmonal valve murmur (-)
✔ ICS IV-V Parasternalis line sinistra: tricuspid valve murmur (-)
✔ ICS IV-V midclavicularis line sinistra: mitral valve murmur (-)

7. Thorax
Lung
(Anterior)
Inspection: symmetrical thoracal expansion, intercostal retraction (-)
Vocal Fremitus Percussion Breath Sound Ronchi Wheezing Egophony
D = S Sonor Sonor vesicular vesicular - - - - - -
D < S Sonor Dull vesicular Vesicular ↓ - - - - - -
D < S Sonor Dull vesicular Vesicular ↓ - - - - - -
D < S Sonor Dull vesicular Vesicular ↓ - - - - - -
D < S Sonor Dull vesicular Vesicular ↓ - - - - - -
D < S Sonor Dull vesicular Vesicular ↓ - - - - - -
Physical Examination

8. Physical Examination
Thorax
Lung
(Posterior)
Inspection: symmetrical thoracal expansion, intercostal retraction (-)
Vocal Fremitus Percussion Breath Sound Ronchi Wheezing Egophony
D = S sonor sonor vesicular vesicular - - - - - -
D = S sonor sonor vesicular vesicular - - - - - -
D < S sonor Dull vesicular Vesicular ↓ - - - - - -
D < S sonor Dull vesicular Vesicular ↓ - - - - - -
D < S sonor Dull vesicular Vesicular ↓ - - - - - -
D < S sonor Dull vesicular Vesicular ↓ - - - - - -
D < S sonor Dull vesicular Vesicular ↓ - - - - - -

9. Abdomen
Inspection : Flat (+), venectation (-), protrude umbilicus (-), no pulsation was seen.
Auscultation : Bowel sounds (+) 10x/minute, other sounds (-)
Percussion : tympanic sound Inferior border of right rib --> dullness (liver)
Inferior border of left rib -> tympani (gastric)
Traube space timpani
Palpation : Abdominal tenderness (+) a/r epigastrium and umbilical
Defensive muscular (-)
Murphy's sign (-)
Superficial mass (-)
Intra-abdominal mass (-)
The patient's face doesn’t look painful when the abdomen is palpated
Blast (-)
Free fluid examination : Shifting dullness (-)
Liver palpation : not palpable
Palpation of the spleen : not palpable
Palpation of McBurney's point: Tenderness (-), pain relief (-), Local muscular defans (-)
Ballotement : Impression was not felt on right/left
CVA tap pain : Right (-/-) left (-/-)
Inguinal Lymphadenopathy (-)
Extremity
Spoon nails (-/-), clubbing fingers (-/-), petechiae (-)
Edema superior (-/-),Oedema inferior ext. (-/-), pitting edema (-)
CRT < 2”
Enlarged lymph nodes (-/-), flapping tremor (-), palmar erythema (-)
Physical Examination

10. Clinical Manifestation

11. Lab 11/11/23 Normal
Haemoglobin 9.8 12.0 – 16.0
Leukocyte 9.63 4.8 – 10.8
Erythrocyte 3.61 4.00 – 5.00
Haematocrit 30.5 36.0 – 48.0
Platelet 547 150 – 400
RDW-CV 13.3 11.0 – 16.0
MCV 84.5 75.0 – 100.0
MCH 27.1 25.0 – 35.0
MCHC 32.1 31.0 – 37.0
Laboratory Results
Lab 11/11/23 Normal
Basophyl% 0.5 0.0 – 1.0
Eosinophyl
%
0.4 2.0 – 4.0
Neutrophyl
%
77.1 46.0 – 73.0
Limphocyte
%
11.2 17.0 – 48.0
Monocyte % 10.8 2.0 – 8.0

12. Lab 11/11/23 Normal
RBG 121 <200
SGOT 10 10 – 37
SGPT 22 12 - 40
Ureum 46.8 15-45
Creatinine 0.8 0.7 – 1.2
Laboratory Results

13. Lab 11/11/23 Value
Macroscopic
Color Yellow Yellow
Clarity Clear Clear
Specific gravity 1.015 1.005 – 1.030
pH 5.0 5.0 – 9.0
Keton Negative negative
Protein Albumin 1+ negative
Glucose Negative negative
Bilirubin Negative negative
Occult blood Negative negative
Nitrit Negative negative
Urobilinogen Normal Normal
Leucocyte Esterase Negative negative
Lab 11/11/23 Value
Sediment
Leucocyte 1-2 2 – 4
Erythrocyte 0-1 0 – 1
Epithel 3-5 8 - 15
Crystal Negative negative
Cylinder Negative negative
Bacteria 10-15 negative
Others Negative negative
Urinalysis
Laboratory Results

14. ECG (11/11/2023)

15. Sinus Tachycardia Q wave : pathological Q (-)
Regular QRS Complex : 0.08 s, RBBB -, LBBB -
Heart Rate 110 bpm ST segment : isoelectric, ST elevation (-), ST depression (-)
Frontal Axis normoaxis T inverted (-), peak tall T (-), U wave (-)
Horizontal Axis: no rotation R/S <1
R V5/6 + S V1 <35 RVH (-), LVH (-)
P wave : 0.08 s, P mitral (-), P pulmonal (-)
PR interval : 0.12 s
Conclusion :
Sinus Tachycardia 110 bpm
ECG Interpretations 12/04/2023

16. Identity Mrs.H / 43 yo
Position AP
Density Enough
Inspiration Enough
Soft Tisse Normal
Bone Intact
Trachea In the middle
Hilus D/S Normal
Mediatinum Wide
Cor hard to evaluate
Hemidiapragha Sinistra (massive fibrotic process)
Dextra (normal)
Costophrenicus
Sinus
Sinistra : hard to evaluate
Dextra : sharp
Parenchym Infiltrat (-)
Conclusion Expertise (-)
massive fibrotic process left hemithorax
Infiltrate (-)
Chest X-ray (12/04/2023)

17. TIMELINE
couple years
ago
• History of
Epigastric
pain and
Nausea
3 days before
admission
• Abdominal
pain
• Nausea
Admission day
• Came to ER
with
abdominal
pain
• Vomiting
profuse

18. Summary of Database
RESUME OF DATABASE
ANAMNESIS PHYSICAL EXAMINATION OTHER EXAMINATION
• Abdominal pain (+)
• Nausea (+)
• Vomit (+)
• Decrease of appetite
(+)
• Soft stool
Objective
KU: looks moderate ill
GCS: E4V5M6
BP: 126/69 mmHg
HR: 134 bpm
RR: 20 bpm
Tax: 37.4oC
SpO2 : 96% on RA
Weight : 48 kg
Height : 155 cm
IMT : 20.0 (normoweight)
VAS : 5
Head/neck : pale conjunctiva (+), icteric
sclera (-), JVP R+1 cmH20 , enlarged
lymphatic (-)
Pulmo: ves (VVV/V<<), rh (---/---), wh (---/-
--)
Cor: BJ 1-2 single, murmur (-), gallop (-)
Abdomen: Distended (-), BS (+), soefl,
tenderness (+) a/r epigastium + umbilical
Extremities: , warm (+/+), edema inferior -
/-, CRT <2 s,
Scoring
Tokyo guidelines 2018  acute
cholecystitis : not met entry criteria
 Acute cholangitis : not met entry
criteria
Alvarado score 4 (unlikely
appendicitis)
Laboratorium 11/11/23
Hb 9.8
MCV 84,5
MCH 27.1
Leu 9.630
N% 77.1
L% 11.2
Trombosit 547.000
GDS 121
Ureum 46.8
Cr 0.8
SGOT 10
SGPT 22
Urinalisis 11/11/23
Warna kuning jernih
BJ 1.015
PH 5.0
Keton (-)
Prot-albumin (+)
Glukosa (-)
Bilirubin (-)
Darah samar (-)
Nitrit (-)
Urobilinogen N
Bakteri 10-15
ECG 11/11/23
Sinus tachycardia, 110 x/m
CXR 11/11/23
Massive fibrotic process left
hemithorax
Infiltrat (-)
PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat/ RSUD Ulin Banjarmasin

19. 1. Abdominal pain + Nausea vomitus
2. Massive fibrotic left hemithorax
3. Anemia NN
PROBLEM LIST
PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat/ RSUD Ulin Banjarmasin

20. CUE AND CLUE Problem List Initial Diagnosis
Planning
Diagnosis
Planning
Therapy
Planning
monitoring
Mrs. H/ 43 yo
- complaints of abdominal pain since 3 days before
entering the hospital
- Abdominal pain felt continuously and
penetrates to the back, but not radiated or
spread to neck, shoulder, or legs
- pain increase when eating foods
- Defecation 2-3 times a day, consistency
was soft, yellow color, mucus (-), blood (-
)/black stools (-)
1. Abdominal
pain + Nausea
vomitus
1.1 Peptic Ulcer
disease
1.2 Gastritis
1.3 GERD
- Benzidin
test
- OMD
- Endoscopy
Non Pharmacology
Soft diet, 1400 kcal/day
Pharmacology
Inj omeprazole 2x1
inj ondansentron 3x4mg
po sukralfat 4x2c
po rebamipide 3x1
inj antrain 3x1 amp (if needed)
Planning Monitoring
- Subjective : pain,
nausea-vomitus
severity
- VS : temp, VAS
- CBC
Planning Education
- Educate about the
condition, suspected
etiology, and
management
- Explain that the
condition still needed to
be diagnosed first
before able to be
definitely treated
- Avoid triggering food :
fatty, sour, spicy
Physical Examination:
VAS 5
HR 110
Physical Examination :
Epigastric tenderness
(+)
Scoring
Tokyo guidelines 2018 
acute cholecystitis : not
met entry criteria
 Acute cholangitis : not
met entry criteria
Alvarado score 4 (unlikely
appendicitis)
Laboratory
Findings:
Laboratorium 11/11/23
Hb 9.8
MCV 84,5
MCH 27.1
Leu 9.630
N% 77.1
L% 11.2
Trombosit 547.000
Ureum 46.8
INITIAL PLAN

21. CUE AND CLUE Problem List Initial Diagnosis
Planning
Diagnosis
Planning
Therapy
Planning
monitoring
Mrs. H/ 43 yo
- Nausea and vomitus 3 days ago. Went to
ER 3 days ago and was advised to be
admitted, but refused the advice
- Given KSR 2x600 mg as to be taken at
home
- Decrease of appetite (+) 3 days due to
nausea and vomiting
2. Severe
hypokalemia
(improved)
2.1 GI loss
2.2 Low intake
Non Pharmacology
- High potassium diet
Pharmacology
IVFD Asering 1500 cc/24
hours
Planning Monitoring
- Motoric strength
- Serum potassium
evaluation
- ECG changes
Planning Education
- Eat food high in
potassium
Physical Examination:
Motoric strength
5/5
5/5
Laboratory
Findings:
Lab 12/04/23
K 3.2
Lab 07/04/23
K 2.5
ECG (12/04/23)
Sinus rhythm, 90
bpm, U wave (-)
INITIAL PLAN

22. CUE AND CLUE Problem List Initial Diagnosis
Planning
Diagnosis
Planning
Therapy
Planning
monitoring
Mrs. H/ 43 yo
- Getting tired quickly during activities (+)
since2 years ago
- Sleeping using two pillows, or waking up
at night because of shortness of breath
were denied
- Hypertension since 10 years ago
3. HF stage B FC
II
3.1 HHD
3.2 IHD
NTproBNP
Echocardiograph
y
Non Pharmacology
• Life style modification
• Low salt < 5 gram/day
Pharmacology
Lisinopril 1x5 mg
Planning Monitoring :
• Subjective : DoE,
othopneu, PND
• Echocardiography
evaluation
Planning Education
• Educate patient about
life style modification
 adjust daily activity,
exercise as tolerated,
BW reduction, healthy
diet, and control the BP
Physical Examination:
JVP 5+2 cm H20
Extremity : edema -/-
Framingharm Criteria:
Mayor : Cardiomegaly
Minor : DoE
Laboratory
Findings:
ECG (12/04/23)
Sinus rhythm, 90
bpm
CXR (12/04/23)
Cardiomegaly (+)
INITIAL PLAN

23. No Date Time SOAP Resident On Duty Supervisor
(Internist)
1 13/04/2023 06.00 Subjective:
Objective: GCS E4V5M6
BP: mmHg
HR : x/minute
RR : x/minute, kusmaul (+)
T : C
SpO2 % Urine Output :
Assessment:
Epigastric pain + nausea-vomitus +
jaundice + elevated liver enzyme +
hyperbilirubinemia direct dominant +
Therapy :
dr. Diah
Sukmawati, SpPD
Progress Note

24. No Date Time SOAP Resident On Duty Supervisor
(Internist)
2 13/04/2023 06.00 Subjective:
Objective: GCS E4V5M6
BP: mmHg
HR : x/minute
RR : x/minute, kusmaul (+)
T : C
SpO2 % Urine Output :
Assessment:
Mild hypokalemia
Therapy :
dr. Diah
Sukmawati, SpPD
Progress Note

25. No Date Time SOAP Resident On Duty Supervisor
(Internist)
3 13/04/2023 06.00 Subjective:
Objective: GCS E4V5M6
BP: mmHg
HR : x/minute
RR : x/minute, kusmaul (+)
T : C
SpO2 % Urine Output :
Assessment:
HF stage B FC II
Therapy :
dr. Diah
Sukmawati, SpPD
Progress Note

26. PROBLEM ANALYSIS
Epigastric pain + Nausea
vomitus
Female Forty
Flatulence
Fatty
Elevated liver enzyme +
Hyperbilirubinemia
dominant direct +
Murphy sign
Hypokalemia
Hypertension
HF stg B FC II
Low intake
GI loss Extrahepatic intrahepatic
Cholecystitis
Cholelithiasis Cholangitis
Fatty liver
disease
Mrs. H/ 43 yo

27. THANK YOU
PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat/ RSUD Ulin Banjarmasin