CASE BASED DISCUSSION

55 years old men with dispneu

Laode Muhammad Sukarno Advisor :

Kamaluddin
dr. M Saugi Abduh, Sp.PD, KKV, FINASIM
30101306973
 PATIENT’S IDENTITY
 Name : Mr. M
 Age : 55 years old
 Sex : Male
 Religion : Moslem
 Job : Worker
 Address : Sendangrejo RT 02/03 Pekunden, Semarang
 Medical Record Number : 01.34.33.53
 Room : Baitul Izzah 2
 Entry Date : 21th Februari 2018
 Date Out : 28th Februari 2018
HISTORY TAKING
MAIN PROBLEM
Dispneu

HISTORY OF PRESENT ILLNESS :

Patient came into the Emergency Room of Islamic Hospital of
Sultan Agung Semarang complained about his disease, He felt
dyspnea about 4 days ago all the time. This complaint was
happened for manny times. Especially when he activity , the
complaint will be better if he got a rest. Patient will be better if
the break in the sitting position. Patient also complained that both
of legs were swelled, and chest pain.
 HISTORY OF ILLNESS
Family’s history of
History of
disease
previous illness • Hypertension history (-)
• DM history (-)
• Same symptom/illness (+) • Asthma and alergy history (-)
• Hypertension history (-)
• DM history (-)
• Asthma history (-)
• Alergy history (-) Sosio-Economic
•
•
Cardiac Disease (-) History
Drug allergy (-) • Hospital cost certified by
• Smoking (+)
JKN NON PBI
 SISTEMIC ANAMNESIS
Onset : 4 days ago
Location : chest
Chronology : Patients had a sudden dispneu while he works
Quality : Patients described his dispneu as heaviness
Quantity : Dispneu felt continously
Modifying factors : Patients feels complaint will be better if he got a
rest. Patient will be better if the break in the sitting position
Other complaints : Patient also complained that both of legs were
swelled, cough, and chest pain.
 GENERAL PHYSICAL EXAMINATION
Patient Status
• Genaral : Weakess
Interpretation : Interpretation :
•Awareness : Composmenyis
Normoweight Normal

Nutrient Status Vital Sign

• Weight : 57 kg • BP : 120/70 mmHg
• Height : 170 cm • HR : 114 x/m
• BMI : 57: (1,7x 1,7) • RR : 20 x/m
= 19,7 • Suhu : 36,6 oC
23/ 02 /2018
23/ 02 /2018
Head : Mesocephal, alopesia (-)

Eyes : Anemic conjuntiva(-/-),

Icteric sclera(-/-) Nose : Symmetric, secret (-), Nostril Breath
(-)

Mouth : Cyanosis (-), dry lips (-),

Ears : Normal shape,
snoring (-)
discharge (-/-)

Neck : Trakhea deviation (-),

Lymph Hypertropy (-),
Increasing JVP (+) 4 cm

Interpretation : Skin : itching (-), redness (-),

Increasing JVP (+) 4 cm jaundice (-), pale (-), slick (-)
 CHEST EXAMINATION - LUNG 23/ 02 /2018

INSPEKSI ANTERIOR POSTERIOR

Static RR : 20x/min, Hyperpigment (-), spider nevi RR : 20x/min, Hyperpigment

(-), atrophy Pectoral Muscle (-), Hemithoraks D=S, (-),spider nevi (-), Hemithoraks 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 (-), enlargement of ICS (-), Palpable pain (-), tumor (-), enlargement of ICS
Stem fremitus decrease (+) (-), Stem fremitus decrease (+)

Percution Sonor Sonor

Auscultation Vesicular (+) decrease, Whezzing (-), Ronchi (+) Vesicular (+) decrease, Whezzing (-),
Ronchi (+) Interpretation =
Stem fremitus decrease (+)
Ronchi (+)
CHEST EXAMINATION - CARDIAC
Inspection : Ictus cordis is seen.
Palpation : thrill (-), epigastric pulse (+), parasternal pulse (-),
sternal lift (-), Ictus cordis is palpable at ICS VI 2 cm lateral from
linea
mid clavicularis sinistra
Percussion  : dull sound
 Upper borderline of heart : ICS II left sternal line
 Waist of heart : ICS III left parastern line
 Lower right borderline of heart : ICS V right sternal line
 Lower left borderline of heart : ICS VI, 2 cm lateral from left mid clavicle line
CHEST EXAMINATION - CARDIAC
Auscultation
 Aortal valve : S1 & S2 standard, additional sound (-)
 Pulmonary valve : S1 & S2 standard, additional sound (-)

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

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

Intepretation :
Cardiomegaly
 ABDOMEN EXAMINATION
Inspection : symetric, sycatric(-), striae(-),enlargement of vena (-),
caputmedusa (-).
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 7 cm
• Spleen : Throbe space percussion (+)  tympani
Intepretation : normal
 EXTREMITY
Ekstremitas Superior Inferior
Oedema -/- +/+
Cold -/- -/-
Jaundice -/- -/-

Intepretation : Oedem on lower

extremity
LABORATORY
TEST
 HEMATOLOGY
DATE : 21 Februari 2018 / 13.43 WIB/ Sultan Agung Islamic Hospital
PEMERIKSAAN HASIL NILAI NORMAL SATUAN
Hemoglobin 13.6 13.2-17.3 g/dl
Hematokrit 34.3 33-45 %
Leukosit 9.18 3.8-10,6 ribu/uL
Trombosit 214 150-440 Ribu/uL
Golongan darah/Rh B / Positif
INTERPRETATION Normal
 KIMIA PEMERIKSAAN
GDS
HASIL
89
NILAI NORMAL
75-110
SATUAN
mg/dl
DATE :
21 Februari 2018 / Cholesterol 198 < 200 mg/dl
13.43 WIB / Sultan Trigliserid 176 (H) < 160 mg/dl
Agung Islamic
Hospital HDL Cholesterol 35 28-63 mg/dl
Direct
LDL Cholesterol 131 (H) 60-130 mg/dl
Direct
Ureum 19 10 - 50 mg/dl
Creatinin Darah 0,95 0.7-1.3 mg/dl
SGOT 32 U/I 0 – 35 U/I
SGPT 28 U/I 0 – 35 U/I
Natrium 140.3 135-147 mmol/L
Kalium 3.79 3.5-5 mmol/L
Chloride 98.6 95-105 mmol/L
INTERPRETATION Dislipidemia
 IMUNOSEROLOGI
DATE : 21 Februari 2018 / 13.43 WIB / Sultan Agung Islamic Hospital

PEMERIKSAAN HASIL NILAI NORMAL SATUAN

HBsAg Kualitatif Non Reaktif Non Reaktif -

INTERPRETATION Normal
X - RAY
DATE : 21 Februari 2018 / 11.24 WIB/ Sultan Agung Islamic
Hospital
Description
Cor : apeks ke laterocaudal, pinggang jantung mendatar
Pulmo : corakan vaskuler tak meningkat
tak tampak gambaran infiltrat
Diafragma setinggi costa 12 poterior
Sinus kostofrenikus kanan kiri suram

KESAN :
◦ KARDIOMEGALI (LV, LA),
◦ PULMO TAK TAMPAK GAMBARAN INFILTRAT
◦ EFUSI PLEURA BILATERAL MINIMAL
ECG
DATE : 21 Februari 2018 / 10.04 WIB/ Sultan Agung Islamic Hospital
Description
Irama : sinus
Rhytme : reguler
HR : 100 bpm
Axis : Lead I (-) aVF (+)  Deviasi Kanan
Transitional Zone : tidak dapat di identifikasi
P wave : normal, P pulmonal (-) P mitral (-)
PR Interval : 0,12, normal
QRS Complex : 0,08, normal,
ST Segment : Normal ST depresi (-), ST elevasi (-)
T wave : T inferted (II,III,aVF) (inferior)

Interpretation : IHD
ECHOCARDIOGRAPHY
DATE : 23 Februari 2018 / Sultan Agung Islamic Hospital

Deskripsi:
• Dimensi Ruang Jantung : membesar di RA + RV
• Dinding LV : menebal di PW
• Wall otion : Global Normokinetik
• Katup jantung : TR severe, PH severe

• Fungsi LV Sistolik baik EF 67 %

• Fungsi RV sistolik baik TAPSE 14 mm
• Fungsi LV diastolic gangguan relaksasi
 ABNORMALITY DATA
Anamnesis X- Ray
1. Dispneu 12. Kardiomegali (LV, LA)
2. Orthopneu Physical Examination
13. Efusi Pleura Bilateral Minimal
3. Swelling lower extremities COR
4. Chest pain 10. Cardiomegaly
ECG
14. IHD
Advance Examination
Physical Examination Laboratory Test
5. JVP 4 cm ECHO
11. Dislipidemia
6. Oedem Lower Extremities 15. Disfungsi LV diastolik
Pulmo 16. Disfungsi RV Menurun
7. Stem fremitus deacresed 17. TR severe, PH severe
8. Auscultation thorax Ronchi 18. Dilatasi RA + RV
(+)
 PROBLEM LISTS
CHF
1 1,2,3,5,6,10,12,14,15,
16,17,18

2 EFUSI PLEURA
7,8,13
DISLIPIDEMIA
11 4
Acute Coronary VHD
Syndrome
4,11,14 3 17,18 5
 CHF
• Ass:
1. Etiologi : Iskemik Heart Disease (IHD), Valvular Heart Disease (VHD)
2. Anatomi : LVH, LAH
3. Fungsional : NYHA IV

• IP Dx : BNP (≥ 35 pg/mL) dan Pro-BNP (≥ 125 pg/mL) and angiography coroner

• IP Tx :
• Pharmacology
1. Furosemid 1 x 40 mg
2. captopril 12,5mg 2x 1
3. bisoprolol 2,5 mg 1 x 1
•Non-Pharmacology :
Low Fat Intake

 Low Salt intake

 Reduce activity

 High fiber Diet

• IP Mx :
• Vital sign, ECG
•IP Ex :
◦Bed Rest/ Restriction of physical activity
◦Sodium and fluid restriction
◦Reducing emotional stress
◦Sit position or a half sleep position
◦Low fat intake
◦Low salt intake
◦High fiber diet
 PLEURAL EFFUSION
• Ass: -
• IP Dx : -
• IP Tx :
• Pharmacology : underlying disease
• Non-Pharmacology : O2 canule 3L/minutes
• IP Mx :
• Vital sign
• IP Ex :
◦ Explain about his diseases, Bed rest, avoid more activity
 DISLIPIDEMIA
• Ass: High intake of cholestrol
• IP Dx : ASCVD score risk
• IP Tx :
• Pharmacology : Atorvastatin 1 x 40 mg
• Non-Pharmacology :
1. Lyfe style management
2. Explain to patients about the condition, and complication that may
occur
3. Exercise 60 minutes with aerobic and resistance training
4. 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
 Acute Coronary Syndrome
Ass :
 Acute Coronary Syndrome : NSTEMI, UA
IP Dx :
cardiac marker,
Ip Tx :
• Non-Pharmacology :
PCI
O2
• Pharmacology :
Aspilet 80mg 1x1
CPG 75 1x1,
ISDN subl. 5 mg 3x1
Nitrokaf 2,5 mg 2x1
IpMx : Vital sign, ECG, laboratory examination
IpEx :
oReducing emotional stress
oReducing of physical activity
oDiet low fat
oControl blood pressure
 VHD
Ass: TR severe PH severe
IP Dx : -
IP Tx :
 Non Pharmacology :
◦ Repair of valvular ( consul to BTKV)
 Pharmacology :
◦ Warfarin 5 mg /day
◦IP Mx:
◦ Monitoring hemodynamic system, INR
IP Ex:

- Education of disease

- Reduce activity