CBD DR Anna - Talita Helga
CBD DR Anna - Talita Helga
CBD DR Anna - Talita Helga
DISCUSSION
Advisor :
Dr. dr. Hj. NUR ANNA CHALIMAH SA’DIYAH, Sp.PD, K-EMD,
FINASIM
By :
Talitha HelgaSafira
30101607744
KEPANITERAAN KLINIK ILMU PENYAKIT DALAM
RUMAH SAKIT ISLAM SULTAN AGUNG SEMARANG
Patient’s Identity
Name : Mr.S
Age : 62 years old
Gender : Male
Religion : Islam
Occupation : Retired Civil Servant
Address : Genuk, Semarang
MR Number : 01090xxx
Room : Endocrine clinic
Examination Date : 20th September 2021
ANAMNESIS
History Taking
Hyperglycemia Overweight
Nutritional Status Based On Who In Asian
General Physical Examination
Interpretation: Normal
Thorax Examination (Lung)
EXAMINATION ANTERIOR POSTERIOR
Inspection – Static RR : 20x/min RR : 20x/min
Thoracoabdominal breathing Thoracoabdominal breathing
Spider nevi (-) Spider nevi (-)
Atrophy of Pectoral muscle (-) Atrophy of Pectoral muscle (-)
Hemithorax D=S Hemithorax D=S
ICS Normal ICS Normal
Diameter AP < LL Diameter AP < LL
Inspection – Dynamic Up and down of hemithorax D=S Up and down of hemithorax D=S
Muscle retraction of breathing (-) Muscle retraction of breathing (-)
Retraction ICS (-) Retraction ICS (-)
Palpation Tenderness (-), Mass (-), tactile fremitus Tenderness (-), Mass (-), tactile
(N) fremitus (N)
Interpretation : Normal
Thorax Examination (Cardiac)
INSPECTION Ictus cordis invisible
PALPATION thrill (-), parasternal impulse(-), sternal lift (-), epigastric pulsation(-)
PERCUSSION • Upper borderline of heart : ICS II left sternal line
• Waist of heart : ICS III left parasternal line
• Lower right borderline of heart : ICS V right sternal line
•Lower left borderline of heart : ICS V, 2cm medial from left midclavicular line
AUSCULTATION
• Aortic 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 ( -)
Interpretation : Normal
Abdominal Examination
INSPECTION symetric, distention (-), sycatric (-), striae (-), enlargement of vein
(-), caput medusae (-), hiperpigmetation (-), edema (-)
AUSCULTATION Peristaltic (+), abdominal aorta bruits (-), splenic artery (-) femoral
artery (-)
PERCUSSION Tympanic, shifting dullness (-), Undulation test (-), Liver dullness (-),
• Liver : Liver span (-), hepatomegaly (-)
• Spleen : Splenomegaly (-)Traube space percussion tympani
PALPATION • Superfisial : mass (-), epigastric pain (-),
• Profundal : epigastric pain (-), liver normal, spleen and kidney
were not palpable,
• Murphy’s sign (-)
• Rovsing sign (-)
Interpretation : Normal
EXTREMITY
SUPERIOR INFERIOR
Kimia Klinik
circumference : 102 cm
Problem List:
1. Type 2 DM
2. Diabetic Neuropathy
3. Metabolic Syndrom
Problem List
01 Type 2 DM
02 Diabetic Neuropathy
03 Metabolic Syndrome
Assessment
Type 2 DM
Assessement Prognosis :
DD : Ad vitam : bonam
Type 1 DM, Diabetes Insipidus Ad sanationam : bonam
Suggesed for treatment Ad fungsionam : bonam
Pharmacological Treatment
Humalog kwikpen inj. 3x20 IU SC Premeal Complication:
Metformin 500 mg 2x1 postmeal afternoon and night • ACUTE :
Non Pharmacological Treatment : • Hypoglycemia
• Hyperglycemia
Balanced nutrition therapy
• CHRONIC :
Low sugar diet
• Microangiopathy
Lifestyle modification • Diabetic Neuropathy
Education : • Diabetic Retinopathy
Healthy diet (type, total, and schedule of food) • Diabetic Nephropathy
Aerobic or physical activity • Macroangiopathy
Regular SMBG ( Self Monitoring Blood Glucose) • Coronary Heart disease
Early detection of diabetic releted complications • Peripheral Arterial disease
Planning • Cerebrovascular disease
Suggesed supporting examination : • Status glicemic
• RHbA1C
• Funduscopy
• ECG
• BGA test
Diabetic Neuropathy
Assessment : Education :
Explain the risk of neuropathy, the importance of
Risk Factor: type I & II DM, age
pain management and reguraly evaluation
Regular clinical check up
Suggesed for treatment :
Healthy diet & lifestyle
Pharmacological Treatment
Gabapentin 300 mg 1 x 1, at night
Tramadol 50 mg 2 x 1, if needed Planning
Suggesed supporting examination :
Microfilament test
Non Pharmacological Treatment :
Balanced nutrition therapy Nerve conduction test
Low sugar diet EMG
Diabetic Neuropathy Symptom (DNS)
Prognosis :
Ad vitam : bonam
Ad sanationam : bonam
Ad fungsionam : bonam
Metabolic Syndrome
Education
• Proper medication
Assessment • Lifestyle modification (3-4 days/week
History of DM, Hypertension exercise, low salt and sugar diet)
and Dyslipidemia • Healthy diet (type, total, and schedule
of food)
Suggesed of treatment Planning
Non Pharmacological Treatment : Suggesed supporting examination :
- Low salt and sugar diet Fasting blood glucose
- Low fat diet, high protein and fiber diet Lipid profile
- Balanced nutrition therapy ECG
- Reduce stress Prognosis :
Pharmacological Treatment : Ad vitam : bonam
Metformin Tab 500 mg 3x1 Ad sanationam : bonam
Simvastatin tab 10 mg 1x1 Ad fungsionam : bonam
Complication :
Microvascular
Macrovascular
Ateroschlerosis
َم ا َأْن َز َل ُهللا َد اًء ِإاَّل َأْن َز َل َلُه ِش َفاًء
"God does not bring down disease
unless He also lowers its antidote." (HR Bukhari).
Thankyou!
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QUESTIONS FROM DR ANNA