CASE BASED

DISCUSSION
MUTHIA RACHMANITA
30101206664

Advisor :
dr. H. M. SAUGI ABDUH, Sp.PD., KKV, FINASIM
Department of Internal Medicine
Medical School of Sultan Agung Islamic University
 PATIENT IDENTITY

Name : Mr. A
Medical Record : 01284042
Age : 51 years old

Gender : Male

Religion : Moslem
Job : Gardener
Address : Purwosari III No. 9 RT 04 RW 03 Tambakrejo, Semarang

Room : Baitul Izzah 1

Entry date : 20 April 2017

Date out : 24 April 2017
 HISTORY TAKING

Main Problem : dypsnea

History of Present Illness

Patient came into the emergency department of Islamic Hospital of Sultan
Agung Semarang, his main complain was dyspneu. He felt dypsneu since
one week ago in activity but more severe in 2 days ago. Patient used more
pillow when slept to decrease his dyspneu. Last week patient felt his leg
become bigger than usual. Patients also complained cough at night and there
is sputum.
HISTORY OF PREVIOUS ILLNESS SOSIO-ECONOMIC HISTORY :
Hypertension history (+) 1 year Hospital cost certified by JKN-PBI
Heart disease (+) 1 year
DM history (-)
Asthma history (-)
Alergy history (-)
Smoking (-)

FAMILY’S HISTORY OF DISEASE

Hypertension history (-)
DM history (-)
Asthma history (-)
Systematic Anamnesis
Chief Complains : dyspnea
Onset : 2 days ago
Location : Chest, feel hard to breath
Chronology : One week ago, he feel hard to breath when he works. His leg
become bigger than usual last week. He cant sleep then he use m ore pillow to decrease h
is dypsneu. He also complain cought and
there is sputum. Fever (-), vomiting (-), nausea (-)
Quality and Quantity : Patients feel more dyspneu when activity
Modification factor: He felt better when break the activity and sit back relax.
Comorbid complains : Patient also felt his leg become bigger than usual last week.
Physical Examination
General : dyspneu
Skin :  jaundice (-), pale (-),

Head : mesocephal

Eyes :  red eyes (-), icteric sclera (-/-)

Ears : normal shape,  ring (-), discharge (-)

Nose : nosebleed (-), discharge (-)

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

Throat : pain swallow(-), hoarseness (-), difficult in swallowing (-)

Neck : enlargement of the gland (-), dilatation vein (+), Jugular vein pressure (+)

Chest : sputum (+), blood (-)

Cardiac : chest pain (-), palpitations (-)

Digestive : abdominal pain (-), nausea (-), vomiting (-)
Interpretation : dypsneu,
Musculoskeletal : weak (-), rigid (-), back pain (-) dilatation vein, increase
Extremity : oedem extremity (-) JVP, sputum (+)
General Status
BMI (Body Mass Indeks)
weight : 52 BMI= 52: (1,65 x 1,65) = 19,11
Intepretation :
Height : 165
Normoweight

General : Dyspneu
Awareness : Fully Aware / Compos Mentis
Vital Sign :
Blood Pressure : 160/90 mmHg
Heart rate: 80 x/minute
Breath Frequency : 24 x/minute
Intepretation : hypertension
Temp : 36,6ooC grade II
GENERAL STATUS
Head : Mesocephal, alopesia (-)
 Eyes : Anemic Conjuntiva(-/-),Icteric sclera(-/-)
 Nose : symmetric, secret (-), Nostril Breath (-)
 Ears : Normal Shape, discharge (-/-)
 Esophagus : Hyperemic (-), pain devour (-)
 Mouth : Cyanosis (-), dry lips (-),
 Neck : Trakhea deviation (-), Lymph Hypertropy (-)
 Extremity : Oedem of lower extremity / upper extremity (-) / (-)

Intepretation : Normal
THORAX - PULMO
INSPEKSI ANTERIOR POSTERIOR

Static RR : 28x/min, Hyper pigment (-), spider RR : 28x/min, Hyper pigment

nevi (-),spider nevi (-), Hemithoraks
(-), atrophy Pectoral Muscle (-), D=S,

Hemithoraks D=S, ICS Normal, Diameter ICS Normal, Diameter AP < LL

AP < LL

Dynamic Up and down of hemitoraks D=S, Up and down of hemitoraks D=S,

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

Palpation Palpable pain(-), tumor (-), Arcus costae Palpable pain (-), tumor (-), Stem
angle < 900, enlargement of ICS (-), fremitus (-)
Stem fremitus (-)
Intepretation : normal
Percution
CARDIAC EXAMINATION

Inspection : Ictus cordis isn’t seen.

Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-),

sternal lift (-).

Percussion  : dull sound

 Upper borderline of heart : ICS II left sternal line
 Waist of heart : ICS III left parasternal line
 Lower right borderline of heart : ICS V right sternal line
 Lower left borderline of heart : ICS VI, 3 cm lateral from left mid clavicle line
Intepretation : cardiomegaly
•Auskultasi
 Aortic valve : S1 & S2 normal, additional sound (-), A1<A2
 Pulmonal valve : S1 & S2 normal, additional sound (-), P1<P2

 Tricuspidal valve : S1 & S2 normal, additional sound (-), T1>T2

 Mitral valve : S1 & S2 normal, additional sound (-), M1>M2

ABDOMEN EXAMINATION
Inspection : symetric, sycatric(-), striae(-)
Auscultation : peristaltic (+)
Palpation :
Superfisial : tight (-), mass (-)
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
EXTREMITIES EXAMINATION

Ekstremitas Superior Inferior

• Oedema -/- -/-
• Cold -/- -/-
• Jaundice -/- -/-

Intepretation : normal
Laboratorium
Examination
20/4/2017 Hasil 20/4/2017 Hasil

Hematology Kimia
Ureum 50 mg/dl
Hemoglobin 14 g/dl

Hematokrit 38,7,5 % Creatinin 1,1 mg/dl

Darah
Leukosit 4,58 ribul/uL
SGOT 35 ug/L
Trombosit 220 ribul/uL
SGPT 21 ug/L
 20/4/2017 Hasil

Kimia
Natrium 141,0 mmol/L

Kalium 4,05 mmol/L

Chloride 105 mmol/L

Intepretation : Normal
Serial ECG
E
K
G

20
-
4
-
17
INTERPRETASI
Irama : Sinus
Regularitas : reguler
Frekuensi : 1500/21 = 71x/menit
Gelombang P : t = 0,2 mv , l = 0,8 det
Interval PR : 0,12 sec
Kompleks QRS : normal
Segmen ST : normal
Gelombang T : normal
Zona transisi : tidak dapat ditentukan (V5)
Axis : Lead I (+) avF (-) = LAD
Kesan : Normo sinus rythm
21
-
4
-
17
INTERPRETASI
Irama : Sinus
Regularitas : reguler
Frekuensi : 300/4 = 75x/menit
Gelombang P : 0,8 sec
Interval PR : 0,12 sec
Kompleks QRS : normal
Segmen ST : normal
Gelombang T : normal
Zona transisi : tidak dapat ditentukan (V5)
Axis : Lead I (+) avF (+) = LAD
Kesan : Normo sinus Rythm
22
-
4
-
17
INTERPRETASI
Irama : Sinus
Regularitas : reguler
Frekuensi : 1500/25 = 60x/menit
Gelombang P : 0,8 sec
Interval PR : 0,12 sec
Kompleks QRS : normal
Segmen ST : normal
Gelombang T : normal
Zona transisi : tidak dapat ditentukan
Axis : Lead I (+) avF (+) = LAD
Kesan : Normo sinus rythm
X-RAY Thorax
COR : Apeks moves to laterolateral.
PULMO: pattern of bronchovascular
and infiltrat in both lung.
Diaphragma and sinus costophrenicus
is normal
KESAN : CARDIOMEGALI.
Echocardiography
Intepretation : MR severe, TR severe, Hipertensi
Pulmonal ringan , dilatation LA, LVH konsentris
Abnormality Data
History Taking
1. dypsneu Radiology Examination
2. orthopneu
Ro Thoraks : ECHO
3. cough
9. Cardiomegali
4. Edema extremities history 11. LVH konsentris
10. Increasing of infiltrate
5. sputum 12. Dilatation LA
broncovasculer 13. Mitral regurgitasi
14. Trikuspid regurgitasi
15. Hipertensi pulmonal
Physical Examination
6. Hipertensi grade II
7. Increase JVP
8. Cardiomegali
 PROBLEM LIST

1.CHF 2. HYPERTENSION 3. VALVULAR HEART

(1,2,3,4,7,8,9,11, STAGE II (6) DISEASE
12) (13,14)

5. HIPERTENSI
4. Pneumonia
PULMONAL
(3,5,10) (15)
 1. CHF
 Ass :
Etiology : Hypertension, Valvular heart disease
 Anatomy : Dilatation LA, LVH konsentris
 Functional : NYHA III
 Ip. Dx : BNP, Pro-BNP
 Ip. Tx :
 Non-Medikamentosa
- Low fat intake - Low water intake
- Low salt intake - elevation chest 30o
- Hight fiber diet
 Medikamentosa
- Infus RL 20 tpm - Valsartan 80 mg 1x1
- Inj. Furosemid 20 mg 2x1 A
- Lactulose syr. 1x2 C
IP. Mx : vital sign, awareness, ecg

IP Ex :
 Bed Rest/Restriction of physical activity

 Sodium & Fluid restriction

 Reducing Emotional stress

 Sit position or a half sleep position

 2. Hypertension Grade II
 Ass : maligna hipertensi and benign hipertensi
Complication : retinopati hypertension, LVH
 IP. Dx : Funduscopy, X-ray chest
 IP. Tx :
 Non pharmacology
- Low salt diet
- Regular physical exercise

 Pharmacology
- Valsartan 80 mg 1x1
- amlodipin 5 mg 1x1
IP Mx : Vital sign

IP Ex : Regular physical exercise

Restriction Salt (5gr/hari)
Consumption vegetables, fruits, low-fat diary
Routine consumption drugs
3. Valvular Heart Disease with
Pulmonal Hypertention
Ass :
- Prevent thromboembolism disease
IP. Dx :-
IP. Tx :
- warfarin 2 mg /day (simptom therapy)
- Repair of valvular (consul to BTKV)

IP Mx : Monitoring hemodynamic system, ECG, INR.

IP Ex :
- explain about the disease
- Reduce activity
 4. Pneumonia
Ass :
etiology: pneumonia spesific
pneumonia non spesific

IP.Dx : culture sputum/ blood culture, BTA

IP. Tx :
- Farmakologi : Inj. Ceftriaxon 1x1 gr
codein 3 x 10 mg
- Non farmakologi : bedrest
IP. Mx : General condition
Ip. Ex
 Bed rest
 Sleep with a pillow propped high
 5. Hipertensi Pulmonal
 Ass :
etiology : valvular heart disease
 IP. Dx : angiografi coronary
 IP. Tx :
-Dorner (beraprost) 20ug 1x1
- sildenafil 25 mg 1x1
 IP Mx : monitoring hemodynamic system, general condition
 IP Ex :
- Reduce activity
- explain about disease
THANK YOU !