CBD

A Women 69 years old with dyspneu

Pembimbing : Penyusun:
dr. MH . Saugi Abduh, SPPD, KKV, FInasim Aziz Rakha Dinarjo
30101507401
IDENTITAS PASIEN
Name : Mrs. W

Age : 69 years old

Gender : Female

Religion : Moslem

Job : unemployed

Address : Dombo RT/RW=02/02 Sayung , Demak

MR number : 01248186

Room : Baitul Izzah 1 – J4

Entry date : June, 22th, 2017

HISTORY TAKING
Patient Problem: Dyspneu

History of Present Illness:

Patients present with complaints about her dyspneu 1
week before came to hospital. complaints are felt the
more the day is getting worse, chest pain (-). Patients
also complain of coughing up for 2 weeks with thick
yellow phlegm. And Then patient also feels nausea (+)
vomiting (-) decreased appetite , and a fever that lost
and arise
HISTORY OF ILLNESS
HISTORY OF PREVIOUS ILLNESS
• Hipertensi -
• DM -
• Dislipidemia History
-
• Heart Disease History + (for 4 years)

• Alergy history -
FAMILY’S HISTORY OF DISEASE
• Hipertensi history (-)

• Diabetes Mellitus (-)

• Heart dissease (-)

• Atsma history (-)

HISTORY OF HABBIT
smoke
• negatif

alcohol
• negatif

exercise
• rare

sugar
• rare

Salty food
• rare
with enough economic impression

SOSIO-ECONOMIC HISTORY

Patient use asurancy BPJS PBI, with

enough economic impression
SISTEMIC ANAMNESIS
Main Complains : Dyspneu
Onset : 7days ago before came to hospital
Location : Chest
Chronology : She Complained that 7 days ago
about her experiencing sudden dyspneu. do not improve with
rest. more the day is getting worse
Quality and Quantity : patients suddenly feel dyspneu
without activity , continue and more getting worse
Modification factor : Better with rest
Comorbid complains : Cough with phlegm , Nausea ,
Fever that lost and arise
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
weakness Compos mentis BMI (Body Mass
GCS E4M6V5 Index) BP : 90/60mmHg
weight : 40kg N : 80x/minute,
RR : 26x/minute,
height : 155cm
irama reguler

Status Nutrition
General

awarness

Vital Sign
Temperatur 36°C
BMI = 40 : (1,55 x 1,55)
= 16,64 (Underweight)
Head • mesochepal,

Eye • blurred vision (-), red eyes (-), icteric sclera (-/-)

Nose • nosebleed (-), discharge (-), nostril breath (-)

Mouth • cyanosis (-), thrush (-), bleeding gums (-)

Ear • hearing loss (-), ring (-), discharge (-)

Neck • trachea in the middle , enlargement of the gland (-) , venous distension (+)

Skin • itching (-), redness (-), jaundice (-), pale (-), slick (-),
 Inspeksi
• Ictus cordis (-)

Palapsi THORAX : COR

• thrill (-), epigastric pulse (-), parasternal pulse (-),
sternal lift (-).
Perkusi

• Upper borderline : ICS II left parasternal line

• Waist : ICS III left parasternal line
• Lower right borderline : ICS IV right sternal line 1cm shift to
medial
• Lower left borderline : ICS VI, 2 cm lateral from left mid Intepretation :
clavicle line Kardiomegali , VHD
Auskultasi
• Aortal valve : S1 & S2 standard, additional sound (-)

Pulmonary valve : S1 & S2 standard, additional sound (-)

Tricuspid valve : S1 & S2 standard, Murmur sound (-)

Mitral valve : S1 & S2, Murmur sound (+)

 INSPEKSI ANTERIOR POSTERIOR

Static RR : 26x/min, Hyper pigment (-), spider nevi RR : 26x/min, Hyper pigment
(-), atrophy Pectoral Muscle (-), Hemithoraks D=S, ICS Normal, Diameter (-),spider nevi (-), Hemithoraks THORAX : PULMO
AP < LL D=S,
ICS Normal, Diameter AP < LL

Dynamic Up and down of hemitoraks D=S, abdominothorakal breathing, (-), Up and down of hemitoraks D=S,
muscle retraction of breathing (+), abdominothorakal breathing (-),
retraction ICS (-) muscle retraction of breathing(-),
retraction ICS (-)

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

Percution dulness dulness

Auskultation Vesicular (-), Whezzing (-), Ronchi (+) Vesicular (-), Whezzing (-), Ronchi
(+)
Intepretation : fluid in pulmo
 Inspeksi
• symetric, sycatric (-), striae (-),enlargement of vena (-),
caput medusa (-), plakat eritematous with soft skuama (-)
ABDOMEN
Auskultasi
• peristaltic (+), 10 x/ menit
• Superfisial : tight (-), mass (-)
• Deep : abdominal pain (-), liver, kidney, and spleen weren’t
palpable, Murphy’s sign (-)
Perkusi
• timpani pada seluruh lapang abdomen, pekak sisi (-),
pekak alih (-).

Palpasi
• tympani, side of deaf (-), shifting dullness (-), pain in heart bun (-)
Liver : right liver span 11 cm, left liver span 6 cm
Spleen :Throbe space percussion (+)  tympani
Intepretation : Normal
EKSTREMITAS
Ekstremitas Superior Inferior

• Oedema -/- -/-

• Cold -/- -/-

• Jaundice -/- -/-

Intepretation : Normal
LAB EXAMINATION
HEMATOLOGY AND CHEMICAL
X-RAY THORAX
COR: Apex to laterocaudal, prominent protrusion of the
pulmonary conus, aortic arcus calcification
Pulmo: vascular pattern increases with vascular bluring. Infiltrates
in the right left perihiler and consolidation on the right
paracardial
The diaphragm and right and left costophrenic sinus do not
appear abnormalities
Bone and soft tissue are good

IMPRESSION:
Kardiomegali (LV, LA, Susp.RV)
Arcus aortic calcification
Oedem Pulmonum's description, tends to be accompanied by
BRPN
ECG
 INTERPRESTASI
Rytme : Atrial
Regularitas : Reguler
Frekuensi : 150x/menit
Axis : LAD
Zona Transisi : V2 (counter clock wise)
Gelombang P :-
Interval PR :-
Komplek QRS : 0,08s , Slurred S wave in v3
Gelombang Q : -
Segmen ST : ST Eelevation V4
Gelombang T : T Tall inV5,V6, T Inveted in lead III , AVF, V2
RVH : S persisten in V5

Kesan : AF Rapid Respon With RVH, T Inverted in III, AVF, V2 and T Tall in V5,v6
ECHOCARDIOGRAPHY
 ECHO SUMMARY
COMMENT :
Dimensions of the heart space : grow up in LA
LV WALL : Not Thickened
WALL MOTION : Global Normokinetik
HEART VALVE : TR Mild , MR Severe , MS Severe
LV Systolic function is good 63%
Systolic RV function is good TAPSE 20mm
The function of LV diastolic is not assessed
Conclusion
Global normokinetics, good systolic LV + RV function, TR Mild MR Severe, MS
Severe, MVA 0.8cm2, Wilkin Score = M: 1, V: 2, U: 2, C: 1 = 7 Dilated LA
ABNORMAL DATA
 ANAMNESIS Phisical Examination
1. Dyspneu 6. Neck : venous distension
2. Cough Pheglm 7. Percusion of cor
3. Nausea enlargement
4. Heart Disease History 8. Palpation lung
5. lost and arising fever 9. Perkution of lung dullness
10. Auskultasi lung Ronchi
(+) , Mitral Valve
Murmur (+)
Supporting Examination
11. Leukosit↑ 15. Chest X Ray =
12. kalium↑ Kardiomegali, Oedem
13. UR/CR ↑ pulmo , BRPN
14. Bilirubin Total ↑ 16. ECG: AF Rapid Respon
With RVH, Iskemik
Inferior and T Tall in
V5,v6
PROBLEM LIST
 Problem List

1. VHD

2. CHF

3. Atrial Fibrilasi

4. Bronkopneumonia

5. Azotemia

6. Hiperkalemia

7. Hiperbilirubinemia

8. Underweight
PROBLEM SOLVING
VHD Ass :
Komplikasi : tromboembolism
IP Dx :cha2dvas
IP Tx :
Pharmacologic
Warfarin 1 x 2 mg
Non farmakologi
konsul spesialis bedah jantung  Surgery repair or replace the valve

IP Mx: vital sign, EKG, INR (2.0-3.0)

IP Ex:
Explain about VHD

Control and follow up the patient condition

Give education if bleeding is one of the side effect from warfarin

medication
CONGESTIVE HEART FAILURE
Ass :
 Anatomi : LVH, LAH , Susp RV
 Fungsional : NYHA IV
 Etiologi
 VHD
IP Dx : - BNP dan Pro-BNP, Echo
Ip Tx
oSpironolactone Tab 1x25mg
oCaptopril 3x6,25 mg
oBisoprolol 1x5mg
IPMx : EKG , Vital Sign
IPEx :
oBed Rest/ Restriction of physical activity
oReducing emotional stress
oSit position or a half sleep position
oHigh fiber diet
 ATRIAL FIBRILATION
1. Ass = Complication for stroke and systemic embolism , and VF
2. Ip. Dx = CHA2DS2-VASc
3. Ip Tx= Bisoprolol 1x5mg(untuk control ritme)
 Warfarin 1 x 2 mg

4. Ip. Mx = EKG,INR
5. Ip. Ex: = Explain about AF
Control and follow up the patient condition
Give education if bleeding is one of the side effect from warfarin
 BRONKOPNEUMONI
1. Ass = Etiologi
Spesifik = M. tubercolussis
non spesifik = H. Influenza . S. Pneumonia , S. Aureus
2. Ip. Dx = BTA , TCM , Sputum Check , Kultur
3. Ip Tx= Empirik ( Inj Ceftriakson 2x1gr & Azitromicin 1x500mg )
antibotik or antifungal according to etiology
 Ambroxol 3x30mg

4. Ip. Mx = Vital Sign , Cough Pheglm , Leukosit , X foto thorak

5. Ip. Ex: = explain with conditions , wear a mask , cough ethics
 AZOTEMIA
Ass :
• Dx: Renal insufficiency , Dehydration
• Risk Factor: DM, Vascular disease (hipertension, vessels disease),
tubulointerstitial disease
• Complication: elektrolit disorder, acidosis metabolic, Anemia
IP Dx : Check GFR , USG kidney, BGA, GDS, check elektrolit
Ip Tx : Non pharmacology:
prevent to terminal stage  fluid balance, diet low protein (0,5/kgBB/day
20 gr/day) 0,6-0,8
Ip Mx : Vital Sign, GFR, fluid balance, (urine output + IWL) re-check ureum
and creatinin
Ip Ex : Do not do heavy activity , Limiting protein intake
Explain about proper daily intake, including type of diet
 HIPERKALEMIA
1. Ass = Complication VF
2. Ip. Dx = EKG
3. Ip Tx= IV CALCIUM GLUCONATE 10% 10ml (iv calcium gluconate more slowly, in
100mL glucose 5% over 20 minutes.) to prevent aritmia
4. Ip. Mx = Elektrolit Check Post Correction
5. Ip. Ex: = Avoid High Potassium Diit Foods (Nuts, Bananas)
 UNDERWEIGHT
1. Ass = DD = MEP
Underlying causes (Anorexia Geriatri , side effect of Digoxin)
2. Ip. Dx = Nutritional Status MNA Score
3. Ip Tx= Aggressive nutrition intervention 40 kkal/kgBB ideal = 1700-1900kkal
Normal 30 Underweight 30-40
1. food fortification (or dietary enrichment) by using natural foods(e.g. oil, cream, butter, eggs)
2. additional snacks, and/orfinger food, inorder to facilitate dietary intake.
3. ONS when dietary food fortification are not sufficient
4. Ip. Mx = Antopometri/ MNA Score
5. Ip. Ex: = 1. Offered nutritional information and educational
2. Share their mealtimes with othersin order to stimulate dietary intake
 HIPERBILIRUBIN
1. Ass = Pre-Hepatik = hemolysis
IntraHepatik (ALT/AST)= Hepatitis Viral
DILI
Hepatitis alkoholik
Autoimun
karsinoma hepar

Post Hepatik (Gama GT,Alkali phosphatase)USG,ERCP

Kolelithiais
carcinoma ampula vater ,
ca caput pankreas
2. Ip. Dx = BilSGOT , SGPT
3. Ip Tx = -
4. Ip. Mx = B1,B2,BT, SGOT/SGPT
5. Ip. Ex: = -
THANK YOU
 GFR
140−𝑈𝑚𝑢𝑟 𝑥𝐵𝐵
GFR= 𝑚𝑔
72𝑥𝑠𝑒𝑟𝑢𝑚 𝑘𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛( )
𝑑𝐿
DEFINITION AND CLASSIFICATION (KDOQI)
 Kriteria CKD (terjadi lebih dari 3 bulan)
Penanda kerusakan ginjal (1 atau - Albuminuria (AER ≥ 30mg/24 jam;
lebih) ACR ≥ 30mg/g (≥3 mg/mmol)
- Abnormalitas sedimen urin
- Abnormalitas elektrolit atau lainnya
yang berkaitan dengan gangguan
tubulus
- Abnormalitas struktur yang
dideteksi dari radiologi
- Riwayat transplantasi ginjal
Penurunan laju filtrasi glomerulus (GFR) GFR < 60 ml/menit/1,73 m2
Old Classification of CKD as Defined by Kidney Disease Outcomes Quality Initiative (KDOQI) Modified and Endorsed by KDIGO

Stage Description Classification Classification

by Severity by Treatment
1 Kidney damage with GFR ≥ 90
normal or increased GFR
2 Kidney damage with GFR of 60-89 T if kidney
mild decrease in GFR transplant

3 Moderate decrease in GFR GFR of 30-59 recipient

4 Severe decrease in GFR GFR of 15-29 D if dialysis

5 Kidney failure GFR < 15 D if dialysis

Note: GFR is given in mL/min/1.732 m²

KDIGO, Kidney
National Kidney Foundation. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Disease: Increasing
Evaluation, Classification, and Stratification. Am J Kidney Dis 2002;39(suppl 1):S1-S266 Global Outcomes
66
RENCANA TATALAKSANA PENYAKIT GINJAL KRONIK SESUAI DENGAN
DERAJATNYA (SUDOYO, 2014)

Derajat LFG (mlmnt/1.73 m2) Rencana tatalaksana

1 ≥ 90 Terapi penyakit dasar, kondisi komorbid,
evaluasi perburukan (progression) fungsi
ginjal, memperkecil risiko kardiovaskuler

2 60-89 Menghambat perburukan (progression)

fungsi ginjal

3 30-59 Evaluasi dan terapi komplikasi

4 15-29 Persiapan untuk terapi pengganti ginjal
5 <15 Terapi pengganti ginjal
 Kidney Disease: Improving Global Outcomes
(KDIGO) CKD Work Group. Kidney Int Suppls.
2013;3:1-150.
 INDIKASI HEMODIALISA
Hemodialisis segera atau
emergency
• Uremia ( BUN >150mg/dL)
• Oliguria (urin <
200ml/12jam)
• Anuria (urin < 50ml/ 12jam)
• Asidosis berat (pH < 7.1)
• Hiperkalemia
• Ensefalopati uremikum
• Neuropati Uremikum
• Hipertermia
• Disnatremia (Natrium > 160
atau < 115 mmol/L)
Hemodialisis kronik, yaitu
hemodialisis yang dilakukan
seumur hidup
• Dimulai apabila dijumpai
salah satu gejala yaitu :
• a. LFG < 15ml/menit,
tergantung gejala klinis
penderita
• b. Malnutrisi atau hilangnya
massa otot
• c. Gejala uremia antara lain
anoreksia, mual muntah,
lethargy
• d. Hipertensi yang susah
dikontrol
• e. Kelebihan cairan
KOMPLIKASI

72
TERIMAKASIH 