CBD

CASE BASE DISCUSSION

Irfan Yuananda
30101407213
Advisor : dr. H. M. SAUGI ABDUH, Sp.PD., KKV, FINASIM

Department of Internal Medicine

Medical School of Sultan Agung Islamic University
2019
Name : Ny. M
Age : 37 y.o.
Gender : Female
Religion : Moslem
Job :-
Address : Dukuh Lor RT 01 RW 01 Toko Penawangan
Grobogan
MR number : 01369655
Room : Baitul Izzah 1 – J1
Entry date : January 15th, 2019
Dead : January 20, 2019
HISTORY OF ILLNESS

PREVIOUS FAMILY SOCIO-

ILLNESS HISTORY ECONOMIC

Hypertension (-) Hypertension (-) Hospital cost is covered by

DM (-) Heart disease (-) “BPJS-PBI”
Alkohol (-) Smoking (-)
Smoking (-)
Heart disease (+) 5 years ago

3
HISTORY TAKING

Main Dyspneu
Problem
Patient came into the emergency department of
Islamic Hospital of Sultan Agung Semarang complained
History of about breathlessness (dyspneu). The complaint arose six
Present
Illness days ago when he was activity. But now she
complained out of breath even when she was at rest.
Patient usually wake up in the midnight when he felt
dyspneu and cough. Patient need more pillow when
slept to decrease his dispneu.
 SISTEMIC ANAMNESIS
Chief Complains : breathlessness (dyspneu)

Onset : 6 days ago

Location : Chest, breathlessness

Chronology : He complain that 6 days ago he feel hard to

breath when daily activity, but 1day ago the breath
feel more uncomfortable, even he take a rest

Quality and Quantity : Patient feel hard to breath everytime and

disturbing activities
Modification factor : He felt better when break the activity and sit back
relax
Comorbid complains : cough
 PHYSICAL EXAMINATION
General : dyspneu Throat : pain swallow(-), hoarseness (-),
Skin : itching (-), redness (-) odinifagia (-)
Neck : enlargement of the gland (-)
Head : headache (-)
Chest : cough (+), sputum (-), blood (-)
Eyes : blurred vision (-), red eyes (-),
Cardiac : chest pain (-), palpitations (-)
icteric sclera (-/-)
Digestive : abdominal pain (-), nausea (-),
Ears : hearing loss (-), ring (-), vomiting (-)
discharge (-) Musculoskeletal : rigid (-), back pain (-)

Nose : nosebleed (-), discharge (-) Extremity : oedem extremity (+)

Mouth : cyanosis (-), thrush (-),

bleeding gums (-)
GENERAL STATUS
BMI (Body Mass Indeks)
Weight : 55 kg BMI= 55: (1,57 x 1,57) = 22,31 kg/m2
High : 157 cm
Intepretation :
Normoweight

General : Dyspneu
Awareness : Compos Mentis (GCS=15)
Vital Sign
• Blood Pressure : 130/90 mmHg
• Heart rate : 130 x/minute
• Breath Frequency : 26 x/minute Intepretation :
• Temp : 36,9oC Tachypneu, Tachycardi,
Dyspneu
 PHYSICAL EXAMINATION
 GENERAL APPEARANCE
SKIN
HEAD, EYES, NOSE, EARS
CHEST, CARDIAC, DIGESTIVE
MUSCULOSKELETAL, EXTREMITIES
8
• Itching (-), jaundice (-), pale (-), hiperpigmentasi
(-)
• Mesocephal, alopesia (-), oedem on face (-)
• Eyes: blurred vision (-), red eyes (-), icteric sclera (-/-), pale
conjungtiva palpebral inferior(-/-)
• Nose: nosebleed (-), discharge (-)
• Ears: normal
• Chest: cough (+), dypsneau (+), sputum purulen (-
), blood (-)
• Cardiac: chest pain (-), palpitations (-)
• Digestive: abdominal pain (-), nausea (-), nausea (-),
vomiting (-)
• Musculosceletal: weak (-), rigid (-), back pain (-)
• Ekstremity : oedem inferior extremity (+), cold extremities (-
)
 LUNG EXAMINATION
INSPEKSI ANTERIOR POSTERIOR

Static RR : 26x/min, Hyper pigment (-), spider nevi RR : 26x/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, INTERPRETA
abdominothorakal breathing, (-), muscle abdominothorakal breathing (-), TION :
retraction of breathing (-), muscle retraction of breathing(-), Tachypneu,
retraction ICS (-) retraction ICS (-) decrease stern
fremitus in both
Palpation Palpable pain(-), tumor (-), Arcus costae Palpable pain (-), tumor (-), Arcus lung, crackles in
angle < 900, enlargement of ICS (-), Stem costae angle < 900, enlargement of both lung (+)
fremitus decrease ICS (-), Stem fremitus decrease

Percution dullness dullness

Auskultation Vesicular (-), Whezzing (-), Crackles (+) Vesicular (+), Whezzing (-),
Crackles (+)
 CARDIAC EXAMINATION 10

• INSPECTION : ICTUS CORDIS ISNT SEEN

• PALPATION : THRILL (-), EPIGASTRIC PULSE (-), PARASTERNAL PULSE (-), STERNAL LIFT (-)
• PERCUSSION : DULL SOUND
- UPPER BORDERLINE OF HEART: ICS II LEFT STERNAL LINE
INTERPRETATION :
- WAIST OF HEART : ICS III LEFT PARASTERNAL LINE 2 CM TO THE LATERAL Cardiomegaly
- LOWER RIGHT BORDERLINE OF HEART : ICS V RIGHT STERNAL LINE
- LOWER LEFT BORDERLINE OF HEART : ICS VI MID CLAVICLE LINE
• AUSCULTATION
 Aortal valve : S1 standard & S2 standard, additional sound (-)
 Pulmonary valve : S1 standard & S2 standard, additional sound (-)
 Tricuspid valve : S1 satndard & S2 standard, additional sound (-)
 Mitral valve : S1 & S2 murmur, additional sound (-)
ABDOMEN EXAMINATION
Inspection : symetric .
Auscultation : peristaltic (+)
Palpation :
• Superfisial : tight (-), mass (-), epigastrial pain (-)
• Deep : abdominal pain (-), liver, kidney, and spleen weren’t
palpable,
• 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
EXTREMITY EXAMINATION
Ekstremitas Superior Inferior

• Oedema -/- +/+

• Cold -/- -/-

• Jaundice -/- -/-

Intepretation : Oedem
 Hematology Normal Value Comment

Hemoglobin 14,5 11,7-15,5 g/dl Normal

Hematokrit 44,2 33-45% Normal
Leukosit 11,37 3,8-11 ribu/uL High

HAEMATOLOGY &
Trombosit 252 150-440 ribu/uL Normal
Blood Type / Rh O/Positive
IMMUNOSEROLOGY
(Imunoserologi)
HbsAg
Non Reaktif Non Reaktif

INTERPRETATION :
Leukositosis
 14

Blood Chemist 18 Januari 2018 Normal Value Comment

Ureum 21 10-50 mg/dl Normal

Creatinine 0,89 0,7-1,3 mg/dl Normal
Natrium 133,8 135-147 mmol/L Low
Kalium 4,56 3,5-5 mmol/L Normal
Chloride 97,4 95-105 mmol/L Normal

calcium 8,8 8,8-10,8 mg/dl Normal

Blood CHEMIST

INTERPRETATION :
Hiponatremia
EKG
IRAMA : Sinus rhytm
REGULARITAS : Ireguler
FREKUENSI : Jumlah kompleks QRS dalam 6 detik x 10 = 13x10
=130x/menit
AXIS : L1 (-) AVF (+) Right Axis Deviation
ZONA TRANSISI :-
GELOMBANG P : 0,12 s
PR INTERVAL : 0,16 s
QRS COMPLEX : 0, 08 s, terdapat RR′ di V1, V2
LVH : R di sadapan ekstremitas ≥20 kk (R di lead III = 30 kk)
RVH :-
ST SEGMEN : ST elevasi (-), ST depresi V3, V4, V5, V6
GELOMBANG T : T inversi lead II, lead III, aVf,V3, V4, V5, V6

Intepretation : Sinus takikardi, RAD,

LVH, T Inverted
• COR : CTR > 50% Apeks cordis
grounded, pinggang jantung bulging,
aortic knob mengecil
• PULMO : Corakan bronkovaskuler
meningkat, sinus phrenicocostalis
kanan kiri tajam
• Diafragma dan sinus kostofrenikus
tak tampak kelainan

Kesan:
COR = Kardiomegali (LV)
Pulmo = gambaran acute edema
pulmonum
ECHO
 ECHOCARDIOGRAPHY 20
Echo Summary
- Dimensi Ruang Jantung : Membesar di LA
- Dinding LV : Tidak menebal
- Wall Motion : Hipokinetik anterior mid apikal
- Katup Jantung : TR severe, PH severe, MS severe
- Fungsi LV Sistolik menurun EF 41%
- Fungsi RV sistolik menurun TAPSE 9 mm

INTERPRETATION :
Hipokinetik segmental, fungsi LV+RV sistolik menurun, TR severe,
PH severe, MS severe dg MVA 0,5 cm, dilatasi LA, specc di LA
DATA ABNORMALITY Lab
15. Leukositosis
21
16. hiponatremia

ECG
History Taking 17. Sinus Tachycardi
1. Breathless Physical Examination 18. T inverted
2. Paroxysmal Noctural 8. Tachycardi
Dyspneu 9. Tachypneu
3. Dyspneu 11. decrease sterm fremitus in
4. orthopneu both lung X-rays
5. Cough with phlegm 12. crackles in both lung 18. Kardiomegali (suspek LV )
6. History of previous heart 13. Cardiomegaly 20. Gambaran acute edema
disease (+) 14. oedem pulmonum

Echo
20. TR severe, PH severe, MS severe
 PROBLEM LIST
1 2
CHF NYHA 4 VHD PH
(1,2,3,4,5,7,8,12,
16,17)

3 4
Hyponatremi (19)
IHD (18)
CHF NYHA 4
 Ass: Etiologi : VHD, IHD

Anatomi : LVH consentric, LA Dilatation

Fungsional : NYHA IV
 IP Dx : BNP, Pro-BNP
 IP Tx :

 Non Pharmacology

 Low Fat Intake  Pharmacology

 Low Salt intake Inj. Furosemide 2 x 2 amp (20 mg)
 Reduce activity Captopril 2 x 12,5 mg
 High fiber Diet Bisoprolol 1x5 mg

Warfarin 1 x 2mg
Ip. Mx : Vital sign, ECG, INR

Ip. EX :

 Bed Rest/Restriction of physical activity

 Reducing Emotional stress

 Sit position or a half sleep position

 High fiber Diet

MAJOR
Pulmonary edem
cardiomegaly
paroxysmal nocturnal dsypneu

MINOR
ankle edem
dyspneu
Cardiomegaly, dyspneu,
oedem extremitas
LVEF 41%
KILLIP CLASSIFICATION 27
 34

ESC ACUTE AND CHRONIC HEART FAILURE GUIDLINE

Aetiologies of Heart
Failure in This Patient
 35

Symptoms and Signs

Typical of Heart Failure
 36

Heart Failure
Algorithm
 Lung oedem 45

1. Assessment
4. Initial Plan of Monitoring
 Transudate : CHF, hipoalbumin
 Eksudate : Tuberculosis  Vital sign
2. Initial Plan of Diagnosis :
 X ray
 Rivalta test
3. Initial Plan of Therapy  Urin output

 Treat underlying disease 4. Initial Plan of Education :

 Non Pharmacology  Reduce activity
O2 canule 3L/minutes
Thoracosintesis with mini WSD
Indication of WSD :
 Hemothorax
 Empiema
 Pneumothorax
 Chylosthorax
Transudate Eksudate
 IHD

1. Assessment : b. Pharmacology
DD Bisoprolol tab 2,5mg 1x1
ISDN subling 5 mg 1x1
– STABIL ANGINA
Clopidogrel 75 mg 1x1
– UAP Aspilet 80 mg 1x1
– NSTEMI Atorvastatin 20 mg 1x1
2. Initial Plan of Diagnosis :
-Cardiac Marker (use troponin) 4. Ip.Mx :
3. Initial Plan of Therapy
 ECG
a. Non Pharmacology
5. Ip.Education :
• Low Fat Intake
 Reducing Emotional stress
• High Fiber diet
 Reducing eat that food contain
• Healthy eating habits
high cholesterol
Hyponatremia 56

1. Assessment : 4. Initial Plan of Monitoring

- electrolyte, vital sign
2. Initial Plan of Diagnosis :
5. Initial Plan of Education :
-
 Increase intake of salt
3. Initial Plan of Therapy
NaCl 0,9% 500 cc = 155 meq/L
(140-129,9) X 55 X 0,6 = 333,3
meq/L
± 2 ¼ flash
VHD 57

1. Assessment 4. Initial Plan of Monitoring

 Etiology : PJR
-INR
 Anatomy : TR severe, PH
severe, MS severe 4. Initial Plan of Education :
 Complication :  Reduced activity
thromboembolism disease
 Education about disease
 Strocke
 CLI
2. Initial Plan of Diagnosis :
-CHAD2S Vascular score
3. Initial Plan of Therapy
- Consult to Sp.BTKV
Hipertensi pulmonal
 Ass :
 Etiology: TR
 Ip. Mx : TTV, KU
 Hipertensi paru primer

 IP.DX : intake low salt

 IP.DX : pulmonary function test

IP. TX :
catheterization heart
oxygen
Dorner ( Natrium beraprost) 25 mg 2x1/2
tab
Sildenafil ( Viagra Revatio)
 55+23+37+8+15+30=168
High risk mortality in hospital (>3%) and outhospital (>8%)
Total score: +2  need oral
anticoagulant
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 Management of Aortic
Regurgitation

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 INR Ratio

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  Obstruction
Tromboemboli
sm Algoritm

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  Non
Obstruction
Tromboemboli
sm Algoritm

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Medical Therapy

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