CBD DR Anna SP - PD Robby Gunawan P21.1
CBD DR Anna SP - PD Robby Gunawan P21.1
CBD DR Anna SP - PD Robby Gunawan P21.1
DISCUSSION
Department of Internal Medicine
Faculty of Medicine Sultan Agung Islamic University
Sultan Agung Islamic Teaching Hospital
2021
CLINICAL SUPERVISOR & CLERKSHIP
STUDENT& CLERKSHIP
CLINICAL SUPERVISOR
STUDENT
● Wet cough
●HISTORY OF PRESENT
ILLNESS
●The patient came to Endocrine clinic of Sultan Agung Islamic Hospital with the purpose of
monthly checkup due to diabetes type II which patient had over 17 years ago (2004). During
the visit patient also complain wet cough that has been felt by the patient since 3 weeks ago.
The wet cough is felt continuously and gets worse especially when the patient get up in the
morning and also during take a bath. Complaints of wet cough accompanied by greyish
sputum/phlegm.The patient itself sometimes also had tingling sensation on both feet. Other
symptoms like blurry vision, ulcer on extremities, decreased urine output were denied by
patient
the patient's economic impression is sufficient
HISTORY OF ILLNESS
HISTORY OF HISTORY OF SOCIO-ECONOMIC
PREVIOUS FAMILY DISEASE HISTORY
ILLNESS
Same Illness: (+) 1 year ago Same Illness : (-)
• The patient's economic
Hypertension History: (-) Hypertension history : (+) Mother
impression is sufficient
DM History : (+) since 2004
DM History : (+) Mother • The patient use BPJS to
Cardiac Disease : (-)
Asthma History : (-) bear the hospital costs
Kidney Disease : (-)
Cardiovascular Disease: (-)
Allergy History : (-)
01
PHYSICAL EXAMINATION
GENERAL PHYSICAL EXAMINATION
Interpretation = cough
accompanied by sputum
COR – THORAX EXAMINATION
EXAMINATION RESULTS
INSPECTION Ictus cordis isn’t seen.
PALPATION Palpable (-), pulsus parasternal (-), sternal lift (-), pulsus epigastrium(-)
Interpretation = Normal
EXAMINATION ANTERIOR POSTERIOR
RR : 20x/min RR : 20x/min
Thoracal breathing Thoracal breathing
Hyperpigmentation (-) Hyperpigmentation (-)
Spider nevi (-) Spider nevi (-)
Inspection – Static
Atrophy M. Pectoralis (-) Atrophy M. Pectoralis (-)
Hemithorax D=S Hemithorax D=S
ICS Normal ICS Normal
Diameter AP < LL Diameter AP < LL
Auscultation Bronchial ( /- ), Wheezing (-), Ronchi (+/-) Bromchial ( / -), wheezing (-), Ronchi (+/-)
Interpretation = Tactile fremitus ( /-), Bronchial breath sound ( / -),
Wet rochi ( /-)
ABDOMINAL EXAMINATION
Inspection : Simetrics, Striae (-), Enlargement of vena (-), Caput medusa (-), Spider nevi (-)
Auscultation : Peristaltic (+), Aorta abdominal bruit (-), A. Lienalis, A. femoralis (-)
Percussion : Flat (+), Dull (+) Shifting dullness (-) Undulation test (-), Liver dullness (-), Liver
span (-), traube space (-)
Palpation
• Superficial : Abdominal tenderness (-), Mass (-), muscular defense (-)
• Deep : Abdominal tenderness (-), hepatomegaly (-), splenomegaly (-)
Interpretation : Normal
EXTREMITY EXAMINATION
Superior (D/S) Inferior (D/S)
Interpretation :
high random blood glucose levels
21/12/2021
LABORATORY EXAMINATION
Interpretation :
high random blood glucose levels
27/12/2021
Test Result Normal Baseline
HbA1c 8,7 <7
Interpretation :
high HbA1c levels
18/08/2021
RADIOLOGY
X RAY THORAX EXAMINATION
(December 21th 2021 at 12:17 PM)
DESCRIPTION :
Pulmo:
• The vascular pattern increases symmetrically
• Thickening on the right and left perihilar
• Diaphragm at the level of the posterior 10 th-11th rib
• The right and left costophrenic sinus in normal state
COR
• normal shape and normal position
• Elongation of aorta
INTERPRETATION :
•Cor : Elongation of aorta
•Pulmo : Bronchopneumonia image
03
ABNORMAL DATA
History Taking
1. History of DM
2. Wet Cough,sometimes cough with greyish sputum
3. Wet cough 1 month ago, History of same illness (+) in
2020
4. Tingling sensation on both feet
Physical Examination
1. tactile fremitus ( / +)
2. Bronchial breathing sound ( / +)
3. wet Ronchi (+/-)
4. Tinglin sensation on both feet
LABORATORY
1. Random blood sugar test 370 mmol/L
(hyperglycemia)
2. Hba1c 8,7 %
X Ray Thorax Examination
1. The vascular pattern increases symmetrically
2. Bronchopneumoonia Image
04
PROBLEM LISTS
PROBLEM LISTS
1. Type II Dibetes Melitus
2. Diabetic Neuropathy
3. Bronchopneumonia
Assesment
Pharmacological Treatment :
Subject : Wet cough, and tingling • Acarbose 50 mgg 2x1
sensation on both feet • Vildagliptin 50mg 2x1
• Gliclazide 50mg 2x1
Object : composmentis, • Humalog Inj. 3x26 unit
TD: 135/76 mmHg, HR: 84 bpm, • Azitromycin 500 mg tab 1x1
Temp : 36.8 ⁰ C, • Acetylsteine 200 mg caps 2x1
RR : 20 bpm • OBH syr 3x1
GDS : 370 mg/dl • Gabapentin 100 mg 1 x 1
HBA1C : 8,7 • Mecobalamin 0,5 mg 3x1