CBD

CASE BASE DISCUSSION

INDRI PUSPITASARI
01.210.6192

Advisor :
dr. H. M. SAUGI ABDUH, Sp.PD., KKV, FINASIM

Department of Internal Medicine

Medical School of Sultan Agung Islamic University
2016
Name : Mr. T
Age : 50 years old
Gender : Male
Religion : Moslem
Job :
Address : Genuksari Rt. 02/07 Genuk, Semarang
MR number : 01-11-99-14
Room : Baitul Izzah 1 – 409.1
Entry date : June 24th, 2016
Date out : June 29th, 2016
HISTORY TAKING

Main Dyspneu
Problem

Patient came into the emergency department of

History
of Islamic Hospital of Sultan Agung Semarang
Present Complained about her abnormal breathing
Illness
(dyspneu). Its started 2 days ago when he rest. Patient
usually wake up in the midnight when he felt
dyspneu. Patients also complained weak, nausea and
cough. Patient need more pillow when slept to
decrease his dispneu.
HISTORY OF ILLNESS
HISTORY OF PREVIOUS ILLNESS SOSIO-ECONOMIC HISTORY :
Hypertension history (+) Hospital cost certified by
DM history (+) JKN NON PBI
Asthma history (-)
Alergy history (-)

FAMILY’S HISTORY OF DISEASE

Hypertension history (-)

DM history (+)

Asthma history (-)

SISTEMIC ANAMNESIS
Chief Complains : Abnormal breathing (dyspneu)
Onset : 2 days ago
Location : Chest, feel hard to breath
Chronology : Patient usually wake up in the midnight when
he felt dyspneu
Quality and Quantity : Abnormal breath dissapear when He wake up
from the sleep and sit.
Modification factor : He felt better when He sit.
Comorbid complains : Weak, nusea and cough
PHYSICAL EXAMINATION
General : dyspneu

Skin : itching (-), jaundice (-), pale (-), slick (-),

Head : headache (-)

Eyes : blurred vision (-), red eyes (-), icteric sclera (-/-)

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 (-)

Cardiac : chest pain (-), palpitations (-)
Digestive : abdominal pain (-), nausea (+), vomiting (-)

Musculoskeletal : weak (+), rigid (-), back pain (-)

Extremity : oedem extremity (-)
GENERAL STATUS
BMI (Body Mass Indeks)
weight : 83 BMI=83: 167 = 29.7
High : 167
Intepretation :
Pra- obesitas

General : Dyspneu
Awareness : Fully Aware / Compos Mentis
Vital Sign :
Blood Pressure : 176/97 mmHg
Heart rate : 110 x/minute
Breath Frequency : 28 x/minute
Temp : 36,6oC
Intepretation :
Hipertension grade II
GENERAL STATUS
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 (-)

 Extremity : Oedem of lower extremity / upper extremity (-) / (-)

Intepretation : Normal
LUNG EXAMINATION
INSPEKSI ANTERIOR POSTERIOR

Static RR : 28x/min, Hyper pigment (-), spider nevi RR : 28x/min, Hyper pigment
(-), atrophy Pectoral Muscle (-), Hemithoraks (-),spider nevi (-), Hemithoraks D=S,
D=S, ICS Normal, Diameter AP < LL ICS Normal, Diameter AP < LL

Dynamic Up and down of hemitoraks D=S, Up and down of hemitoraks D=S,

abdominothorakal breathing, (-), muscle abdominothorakal breathing (-), muscle
retraction of breathing (-), retraction of breathing(-),
retraction ICS (-) retraction ICS (-)

Palpation Palpable pain(-), tumor (-), Arcus costae angle Palpable pain (-), tumor (-), Stem
< 900, enlargement of ICS (-), Stem fremitus fremitus D=S
D=S

Percution Redup Redup

Auskultation Vesicular (-), Whezzing (-), Ronchi (+) Vesicular (+), Whezzing (-), Ronchi (+)
CARDIAC EXAMINATION
Inspection : Ictus cordis isnt seen.

Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-),

sternal lift (-).

Percussion : dull sound

 Upper borderline of heart
 Waist of heart
 Lower right borderline of heart
 Lower left borderline of heart
mid clavicle line
: ICS II left sternal line
: ICS III left parastern line
: ICS V right sternal line
: ICS VI, 2 cm lateral from left
 ...CONT

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 (-)

Intepretation : cardiomegali
ABDOMEN EXAMINATION
Inspection : symetric, sycatric(-), striae(-),enlargement of vena (-),
caputmedusa (-).
Auscultation : peristaltic (+)
Palpation :
Superfisial : tight (-), mass (-)
Deep : abdominal pain (-), liver, kidney, and spleen weren’t
palpable, Murphy’s sign (-)
Percussion : tympani, side of deaf (-), shifting dullness (-)
Liver : deaf(+), right liver span 11 cm, left liver span 6 cm
Spleen :Throbe space percussion (+)  tympani

Intepretation : normal
EXTREMITIES EXAMINATION

Ekstremitas Superior Inferior

• Oedema -/- -/-

• Cold -/- -/-

• Jaundice -/- -/-

LAB. EXAMINATION
1/6/2016 Hematologi 1/6/2016 Imunoserologi
Hb 15,1 g/dl HbsAg Non reaktif
Ht 45,4 %
Leukosit 10,73 ribu/uL
Trombosit 271 ribu/uL GDS 176

27/10/2015 Kimia

Intepretation : Ureum 27 mg/dL

Creatinin darah 0,98 mg/dL
Hiponatremi Natrium 131.8 mmol/L
Hipokalemi Kalium 3.40 mmol/L
Chloride 104,1 mmol/L
Calcium 8.4 mmol/L
X-RAY THORAX

Intepretation :
1. Apex cor bergeser ke laterocaudal.
Pinggang jantung mendatar.
Elevasi broncus ke kiri :
Cardiomegali
2. Pada pulmo corakan
bronchovascular meningkat,
disertai blurring vaskuler : Edem
Pulmo
3. Diafragma dan sudut kostofrenikus
baik.
ECG
IRAMA : Sinus rhytm
REGULARITAS : Regular
FREKUENSI : 83x/menit
GELOMBANG P : 2 x 0,04 = 0,08 (Normal)
PR INTERVAL : 4 x 0,04 = 0,16 (Normal)
QRS COMPLEX : 5 x 0,04 = 0,20 (Melebar) di V5 : LBBB Complete
LV Strength di V5 - V6 : LBBB Complete
ST SEGMEN :-
GELOMBANG T : T inverted di lead V2, V3, V4
ZONA TRANSISI : V3
AXIS : Lead I (-) dan aVF (-) : LAD

Intepretation :
1. LBBB Complete
2. Iskemik di anteroseptal
ECHO
• Dimensi ruang jantung : Tidak membesar

• Dinding LV : Eccentric LVH positif, gerakan global hipokinetik

terutama di inferior

• Katup jantung : Aortic root dilatation, Mild MR, Mild TR

• Fungsi LV sistolik menurun, EF 28%

• Fungsi LV diastolik baik, E/A > 1

Kesan:

LA, LV Dilatasi

concentric LVH +, gerakan global hipokinetik

terutama di inferior

Fungsi sistolik LV menurun 28 %

Gangguan fungsi diastolik E/A >1

Aortic root dilatasi tanpa AR

Abnormal Data
Radiology
History Taking ECHO
Examination
1. Dyspneu, 2. 15.Hipokinetik
Orthopneu, 3.Weak, global
4.Nausea, 5.Cough Ro Thoraks :
16.Fungsi LV Lab
10.Cardiomegaly
(suspected LVH, sistolik menurun Hematology
Physical LAH) 17.LVH 21.Hipokalemi
Examination 11. Edem pulmo 18. LAH 22. Hiponatremia
6.Enlargement of ECG : Konsentrik
the heart from 12.RAD 19. MR Mild
percution 13.RBBB
20. TR Mild
7. Lung oedem Incomplete
8.High blood 14. RVH
preasure : 179/97 15. T inverted di
9. BMI = 29,76 anteroseptal
 PROBLEM LIST
1 2 3
CHF NYHA 4 HIPERTENSION IHD
(1, 2, 3, 5, 6, 7,
10, 11, 13, 14,15, GRADE II ( 12, 13, 16)
16, 17, 18, 19 ) ( 9)

4 HIPONATREMI 5 6
HIPOKALEMI OBESITAS
( 21) (10)
( 20)
 1. CHF NYHA 4
 Ass: Etiologi : Iskemik heart disease, Hypertention heart disease,

cardiomyopathy.

Anatomi : LVH

Fungsional : NYHA IV

 IP Dx : BNP dan Pro-BNP

 IP Tx :

 Non Pharmacology  Pharmacology

 Low Fat Intake  Ramipril (Cardace) 1 x 2,5 mg
 Low Salt intake  Inj. Furosemide 10mg/ml 2 x 1A
 Reduce activity

 High fiber Diet

Ip. Mx : Vital sign, ECG, ECHO
Ip. EX :
 Bed Rest/Restriction of physical activity
 Sodium & Fluid `restriction
 Reducing Emotional stress
 Calory restriction in overweight patient
 Sit position or a half sleep position
 2. 2nd Grade Hypertension

Ass :

Benigna hypertansion (retinopati 1 & 2)

Maligna hypertension (retinopati 3 &4)

Ip Dx : funduscopy, doppler

Ip Tx :

• Non Pharmacology :

 Low salt intake

• Pharmacology :

 Inj. Furosemid 10 mg/ml 2 x 1A

 Ramipril (Cardace) 1 x 2,5mg

Ip. Mx : Vital Sign , electrolit, urin output, uric acid

Ip.Ex :

 Diet low salt

 Consumption vegetable, fruit

 Routine consumption drugs

 3. Ischemic Heart
Disease
Ass: Etiologi : Unstabel Angina

Non ST Elevasi Myocard Infarction ( NSTEAMI)

IP Dx : Mioglobin, CKMB, Troponin I, Troponin T, LDH, Profil Lipid.

IP Tx :

 Non Pharmacology

 Low Fat Intake


 Pharmacology

Aspilet 1 x 80 mg (maintenance)

CPG 1 x 75 mg (maintenance)

Isosorbidinitrat 5 mg k/p

bisoprolol (concor) 1 x 2,5 mg

Ip.Mx : ECG

Ip.Ex :

 Reducing Emotional stress

 Reducing eat that food contain high cholesterol

 Avoid Smoking
 5. Hiponatremi
Ass: Etiologi :

IP Dx :

IP Tx :

pharmacological
 Non – Pharmacology

 NaCl preprat : Inf. NaCl 0,9%

0,5 x BB x delta Na

= 0,5 x 83 x (135-131,8) = 132,8 meq

Ip.Mx : Px. Electrolit post correction (Na,K,Cl)

Ip.Ex :
 6. Hipokalemi
Ass: Etiologi :-

IP Dx : -

IP Tx :Delta K x 0,4 x BB =

3,5 – 3,4 x 0,4 x 83 = 3.32

Farmacology :
 Non Pharmacology :

Stop therapy of Diuretik

Ip.Mx : EKG and electrolite (kalium)

Ip.Ex :

Diet high kalium (banana, potato, pear)

7. Obesitas
Ass : -

Ip Dx : -

Ip Tx : -

Non Farmakologis
Hitung kalori (83x20 = 1660 kal/ hari)
General advice on healthy weight and life style
Ip Mx :
▫ Monitoring weight every week
▫ Waist circumference

Ip Ex :
▫ Diet Low Calory
▫ Diet Low Fat