CASE BASE DISCUSSION

Nefrizal Wicaksono
01.211.6468
Advisor:
dr. H. M. Saugi Abduh , Sp.PD

Patient Identity

Name
Age
Sex
Job
Religion
Status
No. RM
Room
Entry Date
Exit Date

: Mr. A
: 50 years old
: Male
: Farmer
: Moslem
: Umum
: 01256737
: Baitul Izzah 2 (L5)
: June 14th 2015
: June 19th 2015

History Taking
Main Complaint : hard to breathing
Patients came to IGD Sultan Agung
Hospital with problem hard to
breathing. He complained 2 days ago.
Before he came to IGD, he was go to
another doctor but the symptom not
getting better. He also complained
about
common
cold,
insomnia,
decrease appetite 2 days ago. His
symtomp really disturb his daily
activity.

Past illness history

History of Same Illness (-)

Hypertension History (+)
DM History (-)
Heart Dissease History (-)
History of Drug Allergy (-)
History of smoking (+)

Family illness history

No family has the same illness

Social Economic history

The medication fee guaranteed by
Umum

Systemic anamnesis
General
: Weakness
Skin
: Itchy (-), Wound (-), Jaundice (-),
Pale (-)
Head
: Dizziness (-)
Eyes
: Red eye (-), anemic conjunctiva (-),
jaundice sklera (-), odeme palpebra (-)
Ears
: Hearing loss (-), ringing (-),
discharge (-)
Nose
: Epistaxis (-), Discharge (-)
Mouth
: Sianosis (-), Sprue (-), Bleeding
NORMAL
gums (-)

Cont
Neck
: Swelling (-), neck stiffness (-),
Chest : Chest pain (-), palpitation (-)
GIT
: Appetite (+), Nausea (-), vomit (-),
hematemesis (-), abdominal pain (-)
Urogenital
: dysuri (-), hematuri (-), tea
colour of urination (-)
Musculoskeletal : parestesia (-), Low Back Pain
(-)
Extremity
: oedem (-/-), parestesia (-/-) at
inferior ekstremitas, wound (-/-)

PHYSICAL EXAMINATION

Interpretation :
hypertansion
grade 2

Vital Sign
Blood Pressure : 180/100 mmHg
Pulse (HR) : 100 x/
RR : 36 x/
T
: 35,8 c

 Head
Eyes

Nose
Ears
Troat
Mouth

: Mesocephal (-)
: conjunctiva anemic (-/-), jaundice
sklera (-/-)
: Nostril breath (-), discharge (-)
: Discharge (-),
: Hiperemi (-)
NORMAL
: Cyanosis (-), Dry Lips (-)

Thoraks - Cor
Inspection
Ictus cordis can be seen

Palpation
Ictus cordis palpable, thrill (+),
pulsus intercostalis (+), pulsus
epigastric (-), pulsus sternal lift (-)

 Percussion
Upper borderline
: ICS II linea sternalis sinistra
Waist : ICS III linea parasternalis sinistra
Lower right borderline
: ICS V linea sternalis dextra
Lower left borderline
: ICS VI 1 cm lateral from
linea
midclavicularis sinistra

Auscultation
Aorta valve
: S1 & S2 standard, additional sound (-)
Pulmonal valve : S1 & S2 standard, additional sound (-)
Trikuspidal valve
: S1 & S2 standard, additional sound (-)
Mitral valve
: S1 & S2 standard, additional sound (-)

Thoraks - Pulmo
Anterior

Posterior

Static
Inspection

RR : 36x/min, Hyperpigmentation (-),

tumor (-), inflammation (-), spider
nevi (-), Hemithorax D=S, ICS
Normal, Diameter AP < LL

RR : 36x/min,
Hyperpigmentation (-), tumor
(-), inflammation (-), spider
nevi (-), Hemithorax D=S, ICS
Normal, Diameter AP < LL

Dynamic
Inspection

The movement of hemitorax D=S,

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

The movement of hemitorax

D=S, abdominothorakal
breathing (-), muscle retraction
of breathing (-), retraction ICS
(-)

Palpation

Palpation pain (-), tumor (-), Arcus

costae angle < 900, enlargement of
ICS (-),
Stem fremitus D=S

Palpation pain (-), tumor (-),

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

Percussion

Sonor - /-, dullnes +/+

Sonor - /-, dullnes +/+

Auscultation

ronchi (+) , wheezing (-) , vesikuler

(-) D=S
ronchi in the basal (D=S)

ronchi (+) , wheezing (-) ,

vesikuler (-) D=S

Abdomen
Inspection:
Symetric, sycatric(-), striae(-), squama(-)
enlargement of vena (-),
hyperpigmentasi (-), spider nevi (-),
caput medussae (-)

NORMAL
Auscultation :
Peristaltic (+) Normal (20 x/ minutes)

Abdomen

Percussion

shifting dullness (+),

undulation test(-)
Hepar : peka (+), liver
span dextra 10 cm, liver
span sinistra 6 cm
Lien : troube space
tympani (+)

Palpation
Superfisial :
mass (-), abdominal pain
(-) in lumbal dext et sin,
costovertebral knock
pain (-)
Deeper :
Abdominal pain (-)
hepar is not palpable,
lien is not palpable,
kidney is not palpable.

NORMAL

Extremity
Superior

Inferior

Oedem

-/-

-/-

Pitting
Oedema

-/-

-/-

Cyanotic

-/-

-/-

Cold Extremity

-/-

-/-

Capillary
Refille

-/-

-/-

Clubbing
Finger

-/-

-/-

NORMAL

LABORATORY
EXAMINATION

Hematology
Laboratory
Examination

Results

Normal Value

Hb

14,5

13,2 - 17,3

Ht

43,2

33 45

Leucocyte

12,5

3,8 10,6

trombosit

290

150-440

leukositosis

Blood Chemistry
Laboratory
Examination

Results

Normal Value

GDS

136

75-110

SGOT

49

0-50

SGPT

35

0-50

Ureum

56

10 50

Creatinin

1,42

0,6 1,1

Troponi I ultra

0,04

<0,01

Azotemia

ECG

Minggu, 14-6-2015

ECG Intepretation

Rhytm
: Reguler
Frequency : 100 m/s
Axis
: Normal
Transisional zone : P wave
: Duration : 0,08s; Amplitudo : 0,1mV (N)
PR interval : Duration : 0,20s (N)
QRS Kompleks
: Duration : 0,08s (N)
ST Segmen : ST Elevasi
T wave
: T inverted
Other
:Conclusion : STEMI

RONTGEN THORAX

14 June 2015

INTEPRETATION
RESULT :
Cardiomegaly (suspected LVH)
Elongation and calsification of the
aorta
Pulmo suspect pulmonary edema

INTERPRETATION
Echo summary:
Dimensi ruang
jantung
Dinding LV
Wall motion
Katup jantung
Fungsi LV sistolik
menurun 33%
Fungsi RV sistolik
baik TAPSE 23 mm

Kesan:
Global Hipokinetik
Fungsi LV sistolik
menurun
Fungsi RV sistolik
baik
MR moderate
TR mild
Klasifikasi AO RCC

Abnormal Data
Laboratory
and
Radiology
Examination
Physical
Examination
History
Taking
dyspneu

Weakness
ronkhi
enlargement
of the heart
blood pressure
is high

Ro Thoraks :
Cardiomegaly
(suspected
LVH)
Elongation
and
calsification of
the aorta
Pulmo suspect
pulmonary
edema
Ecocardiograp
hy:

Lab
:
hematology
Leukositosis
Lab : Blood
Chemistry
Azotemia
High level of
Troponin I ultra

Problem List

Hypertention Grade II
CHF NYHA IV
Steami
Mitral regurgitation
azotemia

Hipertension grade II
Ass : benigna hypertansion (retinopati 1 & 2)

maligna hypertension (retinopati 3 &4)

IpDx : funduscopy
IpTx :
Non Pharmacology :
Low salt intake
Pharmacology :
Furosemid 1 A iv
Ramipril (Cardace )1x2,5mg

 IpMx :
Vital Sign,elektrolit,
IpEx :
Diet low salt
Consumption vegetable, fruit
Routine consumption drugs

CHF NYHA IV
Ass : diagnose etiology
VHD
IHD
HHD
Diagnose Anatomi
LVH
LAH

Fungsional
NYHA IV

IpDx :
ECHOCARDIOGRAFY
IpTx : Non Pharmacology :
Bed rest
Oxygen NRM 11 liter
Diet low salt

Pharmacology:

Inj. Furosemid 10 mg/ml (2x1

amp)

Preparat pottasium korida 600

mg 1x1

Bisoprolol 1x2,5mg (jika oedem

sudah tidak ada)

Cardase 1x2,5mg

Digoxin 0,25 2 x 1/2

 Ip Mx: General, vital sign, ECG,

echocardiography
Ip Ex :
Bed Rest/Restriction of physical activity
Sodium & Fluid `restriction
Reducing Emotional stress
Calory restriction in overweight patient
Sit position or setengah tidur

STEAMI
Ass :
IpDx :
IpTx :
Aspilet 80 mg 1x1
Clopidogrel 1x75mg
Atorvastatin 1x20mg
ISDN 5 mg sub ling
Bisoprolol 2,5 mg
Morfin
Heparin (anti koagulan)

IpMx : ekg
IpEx :
Bed Rest/Restriction of
physical activity
Sodium & Fluid
`restriction
Reducing Emotional
stress
Calory restriction in
overweight patient
Sit position or setengah
tidur

MITRAL REGURGITATION
Ass :
IpDx :
IpTx :
ramipril 1x2,5mg
Bisoprolol 1x2,5mg
Inj. Furosemid 10
mg/ml (2x1 amp)

IpMx :
echocardiography
IpEx :
Bed Rest/Restriction of
physical activity
Sodium & Fluid
`restriction
Reducing Emotional stress
Calory restriction in
overweight patient
Sit position or setengah
tidur

THANK YOU