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Case Report Session

Preseptor:
Dolvy Girawan, dr., Sp.PD-KGEM, M.Kes

Oleh: Dewi Puspasari


Identitas Pasien
Nama : Ny. I
Jenis kelamin : Perempuan
Usia : 48 tahun
Alamat : Rancajaya, Subang
Pekerjaan : Petani
Agama : Islam
Suku : Jawa
Status : Menikah
Tanggal masuk RS : 15 Juni 2017
Tanggal diperiksa : 15 Juni 2017
Anamnesis
Keluhan Utama: Nyeri kepala sejak 3 bulan yang lalu.

Anamnesis Khusus:
Pasien datang dengan keluhan nyeri kepala sejak 3
bulan yang lalu. Nyeri terasa nyut-nyut, hilang timbul,
terasa sama tiap waktu dan membaik ketika beristirahat.
Nyeri muncul bersamaan dengan munculnya benjolan di
kepala kiri pasien yaitu sejak 10 tahun yang lalu, namun
nyeri hilang ketika itu dan muncul kembali 3 bulan yang
lalu. Sejak pertama muncul benjolan langsung berukuran
besar, ukurannya tidak bertambah seiring bertambahnya
waktu.
Anamnesis
Pasien mengatakan diketahui memiliki tekanan darah
tinggi/hipertensi sejak 3 bulan yang lalu. Hingga saat ini pasien
belum pernah meminum obat anti hipertensi rutin. Pasien suka
memakan makanan yang asin seperti ikan asin, gorengan tahu,
dan tempe. Dalam sehari pasien terbiasa minum lebih dari 1,5L
air. Pasien mengaku terkadang mengalami stress.
Pasien tidak memiliki riwayat merokok, meminum alcohol
dan soda. Pasien tidak pernah dirawat di rumah sakit, tidak
pernah mengalami bengkak, kuning dan mual muntah. Keluhan
air kencing seperti warna teh disangkal pasien, namun BAK
pasien pernah berbau amis dan BAK keluar sedikit-sedikit tapi
sering. Riwayat BAB hitam atau pucat disangkal pasien.
Keluhan tidak disertai penurunan penglihatan ataupun
hilang kesadaran. Di keluarga tidak ada riwayat keluhan yang
sama seperti pasien. Suami pasien memiliki tekanan darah tinggi
dan saat ini mengalami stroke serta lumpuh. Terdapat tetangga
pasien yang juga memiliki keluhan berupa benjolan di kepala.
Pemeriksaan Fisik
Keadaan Umum Tanda-tanda Vital:
Keadaan Umum Tekanan Darah:
- Kesadaran : 165/100
Nadi: 88x/menit
Compos Mentis Respirasi: 17x/menit
- Kesan Sakit : Temperatur: 36oC
Sakit sedang
- Status Gizi :
Obesitas
Pemeriksaan Fisik
Kepala
Tengkorak : Terdapat benjolan di frontal-temporalis sinistra: kenyal, lunak, nyeri
tekan (+) dan berukuran sekitar 3x5 cm, benjolan di rahang bawah kanan dan kiri,
rambut rontok (+)
Wajah : Deformitas (-), asimetris (+), edema (-), rash (-)
Mata :
Sklera : Ikterik -/-
Konjungtiva : Tidak anemis
Otot mata : Baik ke segala arah
Reflex pupil : (+)
Kornea : Jernih
Telinga : Deformitas (-), Sekret (-)
Hidung : Deformitas (-), pernapasan cuping hidung (-), perdarahan (-)
Bibir : Sianosis (-), bibir pecah-pecah (-)
Gigi dan gusi : Gigi berlubang (+), Faring hiperemis (-), Perdarahan mukosa (-),
Sariawan (-)
Lidah :
Pergerakan : Simetris
Permukaan : Tidak ada kelainan
Tremor : (-)
Lain-lain : Typhoid tongue (-)
Rongga mulut : Tenang, tonsil T1-T1
Pemeriksaan Fisik
Leher
KGB : KGB tidak teraba membesar
Tiroid : Pembesaran (-)
JVP : JVP tidak tampak
Trakea : Di tengah

Thoraks
Inspeksi
Bentuk umum : Deformitas (-)
Pergerakan : Simetris
Sela iga tidak melebar
Iktus kordis tidak terlihat
Pemeriksaan Fisik
Thoraks
Palpasi
Perkusi
Paru-paru
Kanan : sonor
Kiri : sonor
Batas paru-hati : ICS V LMCD
Peranjakan : 1 ICS
Cor
Batas atas : ICS III sinistra
Batas kanan : ICS IV Linea parasternalis dekstra
Batas kiri : ICS IV LMCS
Auskultasi
Paru-paru : Suara pernapasan: VBS kanan=kiri, VR kanan=kiri
Suara tambahan: Wheezing -/-, Rhonchi -/-
Cor : Bunyi jantung : S1 S2, murni regular
Murmur (-)
Pemeriksaan Fisik
Abdomen
Inspeksi :
Bentuk : Cembung, lembut

Auskultasi : bising usus (+) 5x/m


Palpasi :
Hepar : hepatomegali (-)
Lien : lien tidak teraba
Nyeri tekan (-)
Perkusi : pekak samping (-), pekak pindah (-),
Ruang traube timpani
Pemeriksaan Fisik
Ekstremitas
Inspeksi :
Deformitas (-)
Palpasi : CRT <2 detik
Sendi : Tidak ada kelainan
Diagnosis
Diagnosis Banding
Hipertensi Stage 2 + Tumor tengkorak/skull
tumor
Hipertensi Stage 2 + Scalp neoplasma

Diagnosis Kerja
Hipertensi stage 2 + Tumor tengkorak
Usulan Pemeriksaan
Complete Blood Count (CBC): Hb, Hct,
leukosit, trombosit
Kolestrol, HDL, LDL, Trigliserida
Serologic tumor marker
MRI
Albumin, total serum protein
Ureum, kreatinin
Urinalysis
Penatalaksanaan
Umum
Diet rendah garam <1,5 gram/hari, penurunan
berat badan (perubahan gaya hidup)
Khusus
Furosemid 40 mg tablet 1x1 pagi hari po
Amlodipine tab 10 mg 1x1 po
Paracetamol 3x500 mg p.o. bila nyeri
Insisi tumor
Prognosis
Quo Ad Vitam : Ad bonam
Quo Ad Functionam : Ad bonam
Quo Ad Sanactionam : Dubia ad bonam
Terima Kasih
Hypertension
Definition (JNC 8)

Hypertension (HTN), high BP, is defined as BP 140/90 mmHg.

Etiology

Majority: unknown primary or essential hypertension. (90%


patients)
Specific cause secondary hypertension.

Primary HTN cannot be cured, but it can controlled with appropriate


therapy (lifestyle modification and medication). Genetic factors play an
important rule in the developing primary HTN.
Secondary HTN is caused by an underlying medical condition or
medication
Risk Factor
Pathophysiology
Primary HTN

Many factors, the 2 primary factor


Hormonal mech. : natriuretic hormone (causes an increase in sodium concentration
in cells), renin-angiotensin-aldosterone system (RAAS) regulates sodium, potassium
and blood volume in arteries angiotensin II and aldosterone

Disturbance in electrolyte: sodium, chloride, potassium


Symptom
HTN is a silent killer, no warning signs or symptoms.
A small amount of people may experience:
- Dull headaches
- Vomiting
- Dizzy spells
- More frequent nosebleeds
These symptom usually appear when BP levels have reached a severe or life-
threatening stage.
Blood Pressure
Arterial BP is the pressure in the arterial wall (mmHg). The 2 arterial BP are systolic
(SBP) and diastolic (DBP). The SBP is the peak/highest value that is achieved when the
heart contracts. DBP is achieved while the heart is at rest (lowest pressure) and the
heart chamber are filling with blood.
Treatment
1. Nonpharmacologic
Lifestyle changes
- Limiting sodium intake < 1500 mg/day (Most dietary salt is found in packaged and
processed food)
- DASH diet (dietary approaches to stop hypertension) emphasizes a food plan high
in fruits, vegetables, whole grains, poultry, and fish while limiting sweets, sugar-
sweetened beverages, alcohol and red meat.
- Exercise (aerobic exercise and resistance training)
Aerobic exercise: walking, jogging, swimming, and biking.
The AHA recommends an average of 40 minutes of moderate to vigorous
intensity aerobic exercise 3 to 4 times a week.

If nonpharmacologic treatment is ineffective, pharmacological therapy is initiated


2. Pharmacologic (medication)
To lower BP and prevent cardiovascular events.
Should be initiated in patients < 60 years old if the systolic BP is persistently 140
mmHg and the diastolic BP is persistently 90 mmHg despite nonpharmacologic
therapy.
If a patient is 60 years old, antihypertensive therapy should be initiated if the
systolic 150 mmHg and diastolic is 90 mmHg.
Pharmacologic
Initial
1. Thiazide diuretics
2. Long acting calcium channel blocker (CCB)
3. Angiotensin-converting enzyme (ACE) inhibitors
4. Angiotensin II receptor blockers (ARBs)

Recommendation for general nonblack populations initial pharmacologc therapy:


Thiazid diuretic, CCB, ACE-I, or ARB).
Recommendation for general black populations initial pharmacologc therapy: Thiazid
diuretic or CCB). Black population have smaller reduction in BP when given ACEI or
ARB.
Algoritm

If patients goal blood pressure is not reached after a month therapy the initial
drugs dose can be increased OR a second drug can be added from one of the classes
recommended.

Combination therapy (2 different classes) can be used as initial therapy if SBP 160
mmHg and/or the DBP is > 100 mmHg OR the SBP is >20 mmHg above goal and/or the
DBP is >10 mmHg above goal.

If 2 medications are not sufficient to meet the BP goal, a third medication can be
added.

Alternative agents can be utilized for HTN if the BP goal is not achieved with first-line
agents (thiazids, CCB, ACEI, ARB).
Thiazide
Thiazide and thiazide-like diuretics have been mainstay of HTN management for longer
period based on consistent evidence in their ability to reduce the risk of heart disease,
heart attack, stroke and death.
Thiazid diuretics inhibit sodium and chloride absorption in kidney.

- Metolazone : effective for patients with poor renal function


- Chlorthalidone : more potent and longer acting (24-72 hours vs. 6-12 hours
hydrochlorothiazide)
Initiated 12.5 mg, target dose between 12.5-25 mg.
- Hydrochlorothiadize: initiated 2x 12.5 to 25 mg/day, target dose of 25-50 mg
- Indapamide

SE: thirst, increase urination, dizziness, low BP, electrolit imbalance.


CCBs
Normally, Ca enters the muscle cells in the blood vessels.

CCB binds to Ca channels found in BV CCBs cause vasodilation (widening) of the BV


this places less pressure on the heart lower BP

SE : headache, dizziness, flushing, swelling in leg and arms, chest pain.


ACE-I
ACEI prevent the formation of angiotensin II by blocking the enzyme that converts
angiotensin I into angiotensin II.
Angiotensin II: - is a hormone causing constriction of BV
- stimulates the release of another hormone called aldosterone, which
hold sodium and water.
ACEI prevent death in patients with heart failure after a heart attack, and in all patients
at high risk for heart complication.

SE: cough (usually begin within the first 2 weeks of therapy therapy should be
discontinue, the cough resolve within a week), low BP, headache, reduction in
glomerular filtration rate, risk of angioedema, high potassium levels.
ACEI increased risk of fetal complication.
ARB
Like ACEI, these agents prevent angiotensins action on BP. However, instead of
preventing angiotensin IIs formation, it blocks angiotensin IIs binding to its receptor.

Because ACEI and ARB have similar mechanism, these 2 drugs should not be used
together for HTN treatment.

ARB have less side effects than ACEI.


SE: cough, low BP, headache, reduction in glomerular filtration rate, risk of
angioedema and high potassium levels.
Like ACEI, these agent should not be used during pregnancy.
Second-line Treatment
- Beta-blocker
Stop the beta-receptor on the heart from being activated heart rate decrease,
decrease low BP.
The reason beta-blockers are second-line therapy is based on studies showing that it
has a higher incidence of heart attack or stroke when used for HTN in patients without
a specific indication for use (e.g. recent stroke or heart attack).
- Aldosterone antagonist
Spironolactone, eplerenone block the action of aldosterone.

- Alpha-blockers
Alpha-1 blockers, central alpha-2 blockers.
Alpha-1 antagonists (doxazosin, prazosin, terazosin) cause small blood vessels to remain
open, which lowers BP.
Alpha-2 agonists including clonidine, guanfacine, and methyldopa work centrally in the
brain to block neurotransmitter from increasing the heart rate and BP.
But doxazosin had a higher incidence of heart failure and cardiovascular events.
SE: dizziness, drowsiness, fatigue, headache.

- Direct renin inhibitor


Aliskerin, works similarly to both ARBs and ACEI, inhibits renin. This agent should not be
used in pregnancy.

- Vasodilators
Minoxidil and hydralazine work by widening the blood vessels to reduce BP. These agent
should be used as a last-line option to treat HTN.
Thank you