CASE BASED

DISCUSSION
AMALIA ZULFA AMANDA
012095832
ADVISOR: DR. M. SAUGI ABDUH,
SP.PD
PERIODE OKTOBER 21TH
DESEMBER 21TH, 2013

Anamnesis
Patients identity
Name : Mr. D
Age
: 71 years old
Sex : Male
Address : Sriwulan RT 04/11 Sayung, Demak
No. CM : 101.59.73
Ward : Baitul Rijjal
Status : Jamkesmas
Date in : November 1th, 2013
Date out : November 5nd, 2013

Main problem
Shortness of breath

History of present illness

A 71-year-old male in acute
distress presented with a chief
complaint of shortness of breath
(dyspnea). The patient had
labored respiration (respiration
rate 36 breaths/min), mild fever
(38C) and cough.

 Over the last 2 months, the patient had

developed shortness of breath during
average daily activities and getting
worst the last two days.
He also feel chest pain that can spread
until his left arm , he already had to
sleep propped up by at least 2 pillows.
Sometimes he feel a sensation of
shortness of breath that awakes him
after 1 or 2 hours of sleep, and is usually
relieved in the upright position.
He also suffered the cough productive of
small amounts of clear sputum since 2
weeks ago.

History of past illness

The patient has no history of
familial illness, hospitalizations,
or trauma. There are no drug
allergies or intolerance. Two
years prior to admittance, the
patient had uncontrolled
hypertension.
History of Asma denied
History of DM denied

Physical Examination

VITAL
SIGN

BMI

BP = 160/100 mmHg

BB = 55 Kg

HR= 106 x/menit

TB = 160 cm
RR= 36 x/menit
T= 38C

BMI

= 21,5 (N)

INSPEKTIO
N
STATIC

DINAMYC

PALPATION
PALPATION

THORAX - PULMO
ANTERIOR

POSTERIOR

RR: 36 x/min, hyperpigmentation

(-), tumor (-), inflammation (-),
spider nevi (-), hemithorax D = S,
ICS Normal, Diameter AP < LL
The movement of hemitorax D =
S, abdominothorakal breathing
(-), muscle retraction of
breathing (-), retraction ICS (-)
Palpation pain (-), tumor (-),
arcus costae angle < 900,
enlargement of ICS (-), stem
Sonor andfremitus
hyposonor at the

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

tumor (-), inflammation (-), spider
nevi (-), hemithorax D = S, ICS
Normal, Diameter AP < LL
The movement of hemitorax D =
S, abdominothorakal breathing (-),
muscle retraction of breathing (-),
retraction ICS (-)

PERCUSSIO
PERCUSSIO
Sonor bottom
and hyposonor
of pulmoat the
N
bottom
of pulmo (-)
N
AUSCULTATI
ronchi
(+) wheezing
AUSCULTATI
ronchi (+) wheezing (-)
ON
vesikuler ()
ON
vesikuler ()
IMPRESSION
IMPRESSION

Palpation pain (-), tumor (-),

enlargement of ICS (-), sterm
fremitus

Sonor and Hyposonor at the

Sonorbottom
and Hyposonor
of pulmo,at the
bottom
pulmo, (-)
ronchi
(+) of
wheezing

ronchi (+) wheezing (-)

vesikuler ()
vesikuler ()

dyspneu
dyspneu

THORAX - COR
INSPECTION
Ictus cordis isnt seen
PALPATION
Ictus cordis is palpable at ICS V, 2 cm lateral from linea mid
clavicula sinistra, thrill (-), pulsus epigastrium (-), pulsus
parasternal (-), sternal lift (-)
PERCUSSION
Dull sound
Upper borderline
Waist
Lower right
borderline
Lower left
borderline
AUSCULTATION
Aorta valve
Pulmonal valve

: ICS II linea sternalis sinistra

: ICS III linea parasternalis sinistra
: ICS V linea sternalis dextra
: ICS VI, 2 cm lateral from linea mid
clavicula sinistra

: S1 & S2 standart, additional sound (-),

AI<A2
: S1 & S2 standart, additional sound (-),

Abdomen
INSPEKSI
Symetric, sycatric (-), striae (-), scuama (-) enlargement of vena
(-), hyperpigmentasi (-), spider nevi (-)
AUSCULTATION
peristaltic (+) Normal (20 x/minutes)
PERCUSSION
Hepar : dullness (+), liver span dextra
dullness (-), shifting
dullness (-), undulation
10 cm, liver span sinistra 5 cm
(-)
Lien : traube space perkusi dull
sound
PALPATION
Deeper:
Superficial :
abdominal pain (-)
massa (-) abdominal
hepar is not palpable, lien is not
pain (-)
palpable, kidney is not palpable.
IMPRESSION
NORMAL

Extremity
Ekstremity
Oedem
Cold extremities
Physiological
Reflect
Ikteric
Impression

Superior
-/-/-

Inferior
+/+
-/-

+/+

+/+

-/-/Lower extremities pitting

oedem

JVP
A distended jugular vein with
visible cannon waves (R+4)

ECG

Interpretation

Rhythm : reguler
Frequency :1500 : 14 = 106 bpm
P wave : 0,04 sec (N)
PR Interval : 0,20 sec (N)
QRS Axis : LAD
QRS complex : 0,08 sec (N)
ST Segment : elevation(-), depresion (-)
T wave : tall (-); inverted (AVL, V1,V5,V6)
Impression : Ischemic antero lateral

Laboratory Result november

2nd, 2013
Examination

Result

Unit

Normal value

Hematology
Hemoglobin

14.3

g/dl

11,7-15,5

Hematocrit

44.0

33-45

Leukocyte

17,1

Thousand/
uL

3,6-11,0

Platelet

166

Thousand/
uL

150-440

Blood group/ Rh

B/
positive

Chemical
GDS

140

mg/dl

<200

cholesterol

180

mg/dl

<200

Total protein

6.96

g/dl

6-8

albumin

4.6

g/dl

3,4 - 4.8

globulin

2.35

g/dl

3,4-4,8

SGOT

41

U/l

0-50

SGPT

31

U/l

0-50

Ureum

28

mg/dl

10-50

Creatinin

1.05

mg/dl

0.6-1.1

Na

139.6

mmol/L

135-147

3.14

mmol/L

3.5-5

Cl

104.9

mmol/L

95-105

CHEST X-RAY
INTERPRETATION :
1. CARDIOMEGALI (LVH)
2. PLURAL EFFUSION
DUPLEX

Problem clustering
From Physical
Examination
From Anamnesis
1. Short
of
breathness
2. Dypsnea
Deffort
3. Cough at night
4. Uncontrolled
hypertension
5. Mild fever

6. RR : 36
7. BP : 160/100 mmhg
8. T : 38 degree of celcious
9. Increas of Sterm fremitus
10. Decrease of vesicular
auscultasion
11. Rochi +
12. Hyposonor in the bottom of
lungs
13. Pitting oedem in lower
extremity
14. A distended Jugular vein R
+4
15. Palpeble Ictus cordis in ICS
VI 2 cm in lateral linea mid
clavicula sinistra

From Advance Examination

EKG : Antero Lateral Iscemic
Chest X-Ray : Cardiomegali an plural
effusion duplex
Leucocytosis : 17,1 thousand/Ul
Hypokalemia : 3, 14 mmol/ L

Problem List
CHF

Plural
Effusion

HYPERTENSIO
N GRADE II

IHD

HYPOKALEMI
A

CHF
1. Short of breathness
2. Dypsnea Deffort
3. Cough at night
4. RR : 36
8. T : 38 degree of celcious
9. Increas of Sterm fremitus
10. Decrease of vesicular auscultasion
11. Rochi +
12. Hyposonor in the bottom of lungs
13. Pitting oedem in lower extremity
14. A distended Jugular vein R +4
15. Palpeble Ictus cordis in ICS VI 2 cm in lateral
linea mid clavicula sinistra
16. EKG : Antero Lateral Iscemic
17. Chest X-Ray : Cardiomegali an plural effusion
duplex

Hypertension Grade II

History of Uncontrolled
hypertension
BP : 160/100 mmhg

CHF
Ass : etiologi : Hypertension Grade II
anatomy : LVH and RVH
fisiology : CHF NYHA III
IP.Dx : Echocardigraphy :heart enlargement or
hypertrophi
IP.Tx :
Non Farmacology: Bed rest
Farmacology

O2 mask 4L/m with nasal canule

Captopril 2 x 12.5 mg
Digoxin 2 x
Spironolacton 2 x 25 mg
Furosemid I.V. 1 x 40mg

IP.Mx : generral appearance, vital sign, ECG, electrolit

and fluid balance

IP
1.
2.
3.
4.

Ex:
Explain about the disease
Taking medication regularly
Routine check of blood pressure.
Daily exercise plan that won't make you too
tired or strain your heart.
5. Follow the diet your health care provider
recommends. Avoid fats such as
shortening, butter, and margarine; olive
and vegetable oil are okay in small
amounts. Also avoid fried foods; eat baked
or broiled foods instead. Stay away from
foods with more than 400 mg of salt
(sodium) per serving. And don't eat more
than 2 grams (less than a teaspoon) of salt
per day.

HYPERTENSION GRADE II
Assesment : hypertension Benigna or
maligna
IP Dx : Funduskopi
Ip Tx :
Non Pharmacology
Diet low fat
Diet low salt < 2gr/day
Farmacology
Bisoprolol 1x 5 mg
IpMx: Vital sign

IP
1.
2.
3.
4.

Ex:
Explain about the disease
Taking medication regularly
Routine check of blood pressure.
Daily exercise plan that won't make you too
tired or strain your heart.
5. Follow the diet your health care provider
recommends. Avoid fats such as shortening,
butter, and margarine; olive and vegetable
oil are okay in small amounts. Also avoid
fried foods; eat baked or broiled foods
instead. Stay away from foods with more
than 400 mg of salt (sodium) per serving.
Read labels so you don't eat more than 2
grams (less than a teaspoon) of salt per day.
6. Keep your blood pressure

IHD
Ass : Non-STEMI ,Unstable Angina
Ip Dx : CKMB , Troponin I dan troponin
T, HS. triponin
Ip. Tx :
Non farmachology : diet low fat,
physiotherapy treadmill
Farmacology :
Aspilet 1x 8mg
ISDN 3x5 mg

 Ip Mx
Vital Sign, profil lipid, EKG,
Ip Ex
Explain about the disease
Maintain weight
Avoid alcohol and cigarette
Diet low fat
Mild Exercise at least 30 minute in everyday
Consumption drug regularly
Routine check of blood pressure.

PLEURAL EFUSION
Assesment : CHF NYHA III or another
Infection
IP Dx : Rivalta test
Ip Tx :
Pharmacology
Inj Cefotaxime 2 x 1 gr
Salbutamol 3 x 4 mg
IpMx: Vital sign

 IP Ex:
Get plenty of rest
Take deep breaths and cough several
times each hour to loosen up mucus and
get it out of your lungs.
Wash your hands with soap and water or
use an alcohol-based hand rub after
blowing your nose or using the bathroom,
and before eating.
Cough or sneeze into a tissue or into
your elbow or sleeve.
If you smoke, stop
Drink several glasses of water a day
Eat a balanced diet so your body can
work its best and heal quickly.

HYPOKALEMIA
Differential Diagnosis: IP Dx : K : 3,14 mmol/L, BB : 55kg
K : (K1- K0) x 0,25 x BB
:
(4 - 3,14) x 0,25 x 55
: 11,28 mEq-1
IP Tx.:
Non Pharmacology: Pharmacology:
Kalium supplement such as ASPAR K 1 x 300mg/day
or
KCL 75 mg/kg/hr dibagi 3 dosis.

IP Mx.: Blood Kalium levels

IP Ex:
Eat more potassium-rich foods: Bananas,
Oranges, Tomatoes, Green, leafy vegetables,
including spinach, salad greens, collards, and
chard, Melons (all kinds), Potatoes
Take a potassium supplement as directed by
your doctor.
Be sure to eat foods or drink fluids that
contain potassium if you are having diarrhea
or vomiting.
Have your potassium levels checked
regularly.
Take all medications exactly as directed.
Avoid foods that are high in salt. Avoid
canned and prepared foods that are high in
salt.

Prognostic
Ad vitam
: dubia ad bonam
Ad sanationam : dubia ad bonam
Ad functionam : dubia ad malam