CASE BASED DISCUSSION

Advisor :
dr. H. Saugi Abduh, Sp.PD, KKV, FINASIM

Arranged by :
Anisa Fauziah
30101306874

Department of Internal Medicine

Faculty of Medicine Sultan Agung Islamic University
2017
 I. PATIENT IDENTITY
• Name : Mrs. G
• Age : 75 yo
• Sex : Female
• Religion : Protestan
• Job : House wife
• Numb of Medical Record : 01331298
• Address : Genuk, Semarang
• Room Care : Baitul Izzah 1
• Date in : 18 October 2017
• Date out : 24 October 2017
• Status Care : Non PBI
 History taking
Main Problem
• Dyspneu

History of present illness

• Patient came to Emergency Unit of Sultan Agung Hospital
with dyspneu since 7 days ago. Her dyspneu becoming more
uncomforably, did not feel comfort when rested. Always felt dyspneu time
by time. Patient also complained that both of legs were swelled
since 7 days ago before coming to hospital. The doctor in
that hospital delivered the patient here for a better
treatment.
 HISTORY TAKING (con’t)
 History of previous disease
Asthma history (-)
Hypertension history (+)
DM history (-)
Heart disease history (+)
Smoking (-)
Maag (-)
Allergy (-)
Drug-induced hyperthermia (-)

 History of family disease

Asthma history (-)
Hypertension history (-)
DM history (-)

 Socio-economic history

Hospital cost is covered by BPJS non PBI

 SISTEMIC ANAMNESIS

Chief Complains : Dyspneu

Onset : 7 days ago

Location : Chest

Chronology : She complained that 7 days ago about her dyspneu.

Quality and Quantity : Her dyspneu becoming more uncomforably, did not
feel comfort when rested. Always felt dyspneu time by time.

Modification factor :-

Comorbid complains : swelling lower extremities.

 II. PHYSICAL EXAMINATION

II.1. Vital Sign

VITAL SIGN

BP HR RR SPO2
Temperature
160/90 mmHg 70 x/minute 24 x/minute 99 %
36°C

Intepretation :
HipertensiGrade 2
 GENERAL STATUS

BMI (Body Mass Indeks)

Weight: 75 BMI= 31,21
High : 155
Intepretation :
Obesity Class 1
II.2. General Status
GENERAL WEAKNESS

AWARENESS Composmentis

HEAD Mesocephal, alopesia (-)

EYES Anemic Conjuntiva (-/-), Icteric sclera (-/-)

NOSES Symmetric, secret (-), Nostril Breath (-)

EARS Normal Shape, Discharge (-/-)

ESOPHAGUS Hyperemic (-), Pain devour (-)

MOUTH Cyanosis (-), Dry lips (-), Stomatitis angularis (-)

NECK Trakhea deviation (-), Lymph Hypertropy (-),

Increaing jugular vein pressure (-)

EXTREMITY Oedem of lower extremity (+)

Intepretation : Oedem on lower

extremity
II. 3. Chest (Lung Examination)
INSPEKSI ANTERIOR POSTERIOR

Static RR : 24x/min, Hyper pigment (-), spider nevi RR : 24x/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,

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

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

Percution Dullness (+) Dullness (+)

Auskultation Vesicular (-), Whezzing (-), Ronchi (+) Vesicular (+), Whezzing (-),
Ronchi (+)

Intepretation :
Ronki (+)
II. 4. (Heart Examination)

INSPECTION Ictus cordis isn’t seen.

PALPATION Ictus cordis is palpate at SIC VI linea mid clavicula sinistra

thrill (-)
pulsus epigastrium (-), pulsus para-sternal (-), sternal lift (-).

PERCUSSION - Upper borderline of heart : SIC II linea sternalis sinistra

- Waist of heart : SIC III linea para sternalis sinistra
- Lower right borderline of heart : SIC V linea sternalis dextra
- Lower left borderline of heart : ICS VI, 2 cm lateral from left mid
clavicle line

Intepretation : Cardiomegaly
 CARDIAC

• Auscultation
• Auscultation
 Aortal valve : S1 & S2 standard, additional sound (-)
 Aortal valve : S1 & S2 standard, additional sound (-)
 Pulmonary valve: S1 & S2 standard, additional sound (-)
 Pulmonary valve: S1 & S2 standard, additional sound (-)
 Tricuspid valve : S1 & S2 standard, additional sound (-)
 Tricuspid valve : S1 & S2 standard, additional sound (-)
 Mitral valve : S1 & S2 standard, additional sound (-)
 Mitral valve : S1 & S2 standard, additional sound (-)

Intepretation : Normal
 II. 5. Abdomen Examination

Inspection : symetric, sycatric (-), striae (-), enlargement of vena (-), caput
medusa (-).
Auscultation : peristaltic (+)
Palpation:
• Superfisial : tight (-), mass (-), epigastrial pain (-)
• Deep : abdominal pain (-), liver, kidney, and spleen weren’t palpable,
Murphy’s sign (-)
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
II. 6. Extremity
EXTREMITY SUPERIOR INFERIOR
(D/S) (D/S)
OEDEM -/- + /+

COLD EXTREMITY -/- -/-

PHYSIOLOGICAL +/+ +/+

REFLEX
ICTERIC -/- -/-

Intepretation : Oedem on lower extremity

III. ADVANCE EXAMINATION
HEMA
TOLG
Y

Echoc
ardio
graph
y

Thorax
X-RAY
LABORATORIUM EXAMINATION
 III. 1. Hematology
18/10/2017

HEMATOLOGY RESULT NORMAL VALUE

DARAH RUTIN 1

Hemoglobin 13.2 g/dl 11.7-15.5 g/dl

Hematokrit 42,5 % 33 – 45 %

Leukosit 15.16 ibu/uL 3,6 – 10,0 ribu/uL

Trombosit 259 ribu/uL 150 – 440 ribu/uL

Golongan darah/ Rh O/positif

KIMIA

Ureum 30 mg/dl 10 – 50 mg/dl

Creatinin Darah 1,26 mg/dl 0.6 – 1,1 mg/dl

Gula Darah Sewaktu 207 75-110 mg/dl

Cholesterol 205 < 200 mg/dl

LDL Cholesterol Direct 137 60-130 mg/dl

HDL Cholesterol Direct 47 37-92 mg/dl

Trigliserid 75 < 160 mg/dl
Uric Acid 5,9 2.6-5.7 mg/dl
Bilirubin Total 0,72 0,1-1,0 mg/dl
Bilirubin Direk 0.35 0-0.2 mg/dl
Bilirubin Indirek 0,37 0-0.75 mg/dl
SGOT 66 0-35 U/l
SGPT 52 0-35 U/l
Natrium 106.9 95-105 mmol/L
Kalium 238.5 71-104 mmHg
Chloride 243.3
Interpretation :
Azotemia
Hiperlipidemi
 Interpretation
 ↑ Cholesterol

 ↑ LDL Cholesterol Direk

 ↑ Kreatinin
III. 2. ECG
ECG 18/10/2017
Interpretation
• Rhytm : Sinus
• Regularitas : Reguler
• Frekuensi : 68 x/menit
• Axis : lead 1 = +, AvF = +  NAD
• Zona Transisi :-
• Gelombang P : normal
• Interval PR : 0,20 detik
• Komplek QRS : 0,12 detik
• Gelombang Q : normal
• Segmen ST : normal
• Gelombang T : T inverted pada lead I dan
aVL

Kesan : LBBB
III. 3. Thorax X-Ray

11/8/2017

Kesan :
COR : Cardiomegali Susp LVH
PULMO : susp Congestive Paru
• CTR = A + B / C X100 %
= > 50 %
Echocardiography
 III. 4. Echocardography
20/10/2017

Kesan :

Hipokinetik Segmental

Fungsi LV Sistolik menurun

Fungsi LV diastolik menurun

Dilatasi LA, Hipertropi PW, MR moderate

 V. DATA ABNORMALITY
HISTORY PHYSICAL EXAMINATION ADVANCE EXAMINATION
TAKING
3. Hipertensi grade 2 7. Cholesterol (H)
4. Cardiomegaly 8. LDL Cholesterol Direct
1. Dyspneu
(H)
5.Oedema of lower
2. Swelling lower 9. Kreatinin (H)
extremities
extremities
6. Ronki (+)

ECG : Chest X-Ray : Echocardiography :

10. LBBB 11. Cardiomegaly Hipokinetik Segmental

12. Congestive Paru Fungsi LV Sistolik Menurun

Fungsi LV diastolik menurun
Dilatasi LA, Hipertropi PW, MR
moderate
 PROBLEM LIST
1 2 3
CHF NYHA IV
CHF NYHA IV Hipertension Stage 2 VHD
- Dyspneu
Hipertension Stage 2 VHD
- Dyspneu
- Cardiomegaly from PF - TD 160/90 mmHg - Echo : MR Moderate
- Cardiomegaly
-. Oedema offrom
lowerPF
extremities - TD 160/90 mmHg - Echo : MR Moderate
-. Oedema of lower extremities
- Chest X-Ray Cardiomegaly
- Chest X-Ray Cardiomegaly

4 5 6
Dislipidemia Azotemia Obesity (class 1)
Dislipidemia Azotemia Obesity (class 1)
- BMI 31,21
- Cholesterol : 205 -Ureum : 30 - BMI 31,21
- Cholesterol : 205 Direct 137
- LDL Cholesterol -Ureum : 30 : 1,26
- LDL Cholesterol Direct 137 -Kreatinin
-Kreatinin : 1,26

7 LBBB
LBBB
- ECG : LBBB
- ECG : LBBB
 CHF NYHA 4
 Ass: Etiologi : Hypertension Grade 2

 VHD

 IHD

Anatomi : LVH

Fungsional : NYHA IV
 Pharmacology
 IP Dx : Biomarka examination  Furosemide 0,5-1mgKgBB
 - Brain natriuretic peptide (BNP)
 - Pro-BNP 40 mg 2 x1
 Angiografi Koroner
 Captopril 12,5mg 2X1

 IP Tx :
 Carvedilol 6,25 mg 2x1

 Non Pharmacology  Spironolacton 25 mg 1X1

 Reduce activity  Laktulosa syr 1x1

 Low Salt intake
Ip. Mx : Vital sign, ECG

Ip. EX :
 Bed Rest / Restriction of physical activity

 Reducing Emotional stress

 Sit position or a half sleep position

 High fiber Diet

 HYPERTENSION GRADE 2

Ass :
- Hypertension Benign
- Hipertension Malign

Ip Dx : Funduscopy

Ip Tx :
• Non Pharmacology :

 Life style modification

 Low salt intake

 Pharmacology :
Captopril 12,5mg 2X1
Amlodipin 10 mg 1X1 (night)

Ip. Mx : Vital Sign

Ip.Ex :
Diet low salt
Stay away from stress
Increase mild exercise
Routine consumption drugs
Routine check of blood pressure
 VHD

 Assesment
IP. Mx
MR moderat

Monitoring hemodynamic system, INR (2-3)

IP. Dx -

IP. Ex
IP. Tx
-Education of disease
Non pharmacology
-Reduce activity
Repair of valvular (consul BTKV)

Pharmacology
Warfarin 5 mg/ day
 DISLIPIDEMIA

• Ass : High intake of cholestrol

• IP Dx : ASCVD score risk

• IP Tx :

• Pharmacology :

Atorvastatin 1 x 80 mg PO

Non pharmacology

Lyfe style management

Explain to patients about the condition, and complication that may occur

• Exercise 60 minutes with aerobic and resistance training

• Achieve ideal body mass index and body weight

• Ip.Mx : Cholesterol total, HDL, LDL, Trigliserid

• Ip.Ex :

• Low diet of cholestrol

• Eat high fiber diet and low fat

• Reduce fatty food, soda and junk food

• Low exercise regularly

 AZOTEMIA

Ass : insufisiensi renal

IP Dx : Check GFR , kidney usg

Ip Tx :
Principal thearpy : inhibit progressivity

• Non pharmacology
Limitation of protein intake (0.6-0.8/kgBB/day)

Control Blood pressure

Ip Mx : Vital Sign, GFR, awareness, fluid balance, re-check ureum and
blood creatinin

IpEx :
Do not do heavy activity
Sufficient rest and take medication regularly
Explain about proper daily intake, including type of diet and food
Routine Control of Blood Pressure
 Laju Filtrasi Glomerulus
(LFG) :
=

= (140 - 75) x 75 / 72 x 1.26

= 53,7 X 0.85
Grade III A
= 45.64
 OBESE class 1

• ASS : - • IP Mx: - Monitoring weight

- Waist circumference
• IP Dx : -
• IP Ex: - Education of obesity
• IP Tx: Non Pharmacology - Diet low calori
- Dayli Calori - Diet low fat

- Physical Exercise

- Change of dietary habit

• Basal Metabolic Rate (BMR)

Overweight : 15-20 kal/body weight

So, the calori patient :

15 X 75 : 1125-1500 kalori
 LBBB

Ass: Etiologi : IHD : Unstable Angina, NSTEMI

IP Dx : Mioglobin, CKMB, Troponin I, Troponin T

IP Tx :
 Non Pharmacology

 Low Fat Intake

 High Fiber diet

  Pharmacology
Aspilet 1 x 80 mg
CPG 1 x 300 mg
Isosorbidinitrat 5 mg (bila nyeri dada)

• Ip.Mx : ECG

• Ip.Ex :

 Reducing Emotional stress

 Reducing eat that food contain high cholesterol

Alhamdulillah
Ya ALLAH
Thank You
 Hiperbilirubin

• Ass :
Intrahepatal Ip Tx :
Ekstrahepatal Pharmacology :
Curcuma 3X1
Ip Dx : gamma gt, alkali fosfatase, test
serology hepatitis virus (anti HAV, anti Non Pharmacology :
HCV, HCV RNA kualitatif, biopsi hati. Low fat intake
Ip. Mx : vital sign, bilirubin, transaminase

Ip.Ex :
 Diet low fat
 Routine check of bilirubin