CASE BASED

DISCUSSION
Department of Internal Medicine
Faculty of Medicine Sultan Agung Islamic University
Sultan Agung Islamic Teaching Hospital
2021
 CLINICAL SUPERVISOR & CLERKSHIP
STUDENT& CLERKSHIP
CLINICAL SUPERVISOR
STUDENT
Robby Gunawan
dr. H. M. Saugi Abduh, Sp. PD K-KV, FINASIM (30101607736)
Internist & Cardiovascular Consultant (CLERKSHIP STUDENT OF
INTERNAL MEDICINE
(CLINICAL SUPERVISOR) DEPARTMENT)
 PATIENT’S IDENTITY
• Name : Ms. U
• Patient ID : 01-40-XXX
• Age : 36 years old
• Sex : Female
• Religion : Moeslim
• Address : Donorejo, Demak
• Occupation : Housewives
• Room : B. Izzah 1
• Date of Examination : 21/12/2021
• Class : BPJS Non PBI
 HISTORY TAKING
●MAIN PROBLEM

● Shortness of breath
●HISTORY OF PRESENT
ILLNESS
●The patient came to the ER Sultan Agung Islamic Hospital (18/12/2021) with the main
complaint of shortness of breath. Complaints of shortness of breath has been felt by the patient
since 2 days ago. Shortness of breath is felt continuously and gets worse during night especially
when the patient laying down. Frequently the patient waking up while sleeping at night.
Complaints are reduced if the patient by sits and leaning to the wall or bed. Complaints of
shortness of breath accompanied by chest pain, and dry cough, the chest pain itself that occur
when the patient got cough. Other complaints such as, fever, nausea and vomiting were denied
by the patient.
 HISTORY OF ILLNESS
HISTORY OF HISTORY OF SOCIO-ECONOMIC
PREVIOUS FAMILY DISEASE HISTORY
ILLNESS
Same Illness: (+) 2011 Same Illness : (-)
• The patient doesn’t have a
Cardiovascular Disease: (+) since 2011 Hypertension history : (-)
smoking habit
Hypertension History: (-)
DM History : (-) • The patient use BPJS to
DM History : (-)
Asthma History : (-) bear the hospital costs
Dislipidemia History : (-)
Cardiovascular Disease: (-)
Asthma History : (-)
Allergy History : (-)
 01
PHYSICAL EXAMINATION
 VITAL SIGN
19/12/2021
o General Impression : Shortness of breath
o Consciousness : Composmentis (GCS = 15)
o Vital Sign
 Blood Pressure : 118/88 mmHg
 Heart Rate : 90x/menit
Interpretation : high
 Respiration Rate : 29x/minute
respiratory rate
 Temperature : 36,5oC

 SpO2 : 99% with 3L of nasal cannula

 VITAL SIGN
24/12/2021
o General Impression : Shortness of breath
o Consciousness : Composmentis (GCS = 15)
o Vital Sign
 Blood Pressure : 82/57 mmHg
 Heart Rate : 44x/menit
Interpretation :hypotension,bradycar
 Respiration Rate : 20x/minute dia
 Temperature : 36,5oC

 SpO2 : 99% with 3L of nasal cannula

 VITAL SIGN

o General Impression : poor

o Consciousness : sopor (GCS = E3M5Vaph)
o Vital Sign
 Blood Pressure :70/44 mmHg
 Heart Rate : 104x/menit
Interpretation : high respiratory
 Respiration Rate : 28x/minute rate,show sign of shock

 Temperature : 36,8oC

 SpO2 : 100% with 3L of nasal cannula

 NUTRITIONAL STATUS
 Weight : 42 kg
 Height : 160 cm
 BMI (Body Mass Index) :

BMI = BB/TB2
= 42 kg / (1.6m) 2

= 42/2.56 Interpretation :
=
16,40 kg/m 2
Underweight
NUTRITIONAL STATUS BASED ON WHO AND
ASIA-PACIFIC GUIDELINES
 GENERAL PHYSICAL EXAMINATION
Head : Mesosefal (+)
Eye : Conjungtiva Anemi (-/-), Sclera Icteric (-/-)
Nose : Simetric (-), nostril breath (-)

Ear : Normal shape, discharge (-/-), hearing loss (-)

Face : Edema (-), moon face (-)

Skin : Malar rash (-), discoid rash (-), well turgor (+)
Mouth : Cyanosis (-), dry lips (-), snoring (-)
Neck : Trachea deviation (-), lymph hypertrophy (-),Increasing JVP (+) 5cm + 4cm H2O
Extremities : normal
Interpretation :Right Heart Decompesation
 THORAX EXAMINATION THORAX
EXAMINATION
Inspection –
ANTERIOR
Thoracal breathing,
(CHEST)
POSTERIOR
Thoracal breathing,
Static Hyperpigmentation (-), Hemithorax
D=S, Diameter AP < LL
EXAMINATION
Hyperpigmentation (-), Hemithorax
D=S, Diameter AP < LL

Inspection – Up and down of hemithorax D=S Up and down of hemithorax D=S

Dynamic Muscle retraction of breathing (-) Muscle retraction of breathing (-)
Retraction ICS (-) Retraction ICS (-)

Palpation Tenderness (-), Mass (-) Tenderness (-), Mass (-)

Left tactile fremitus decrease Left tactile fremitus decrease
Percussion Sonor Sonor
Auscultation Vesicular (+/+), Wheezing (-), lung Vesicular (+/+), Wheezing (-), lung
basal wet crackles (-/+) basal wet crackles (-/+)

Interpretation : Pulmonary edema

 CARDIAC EXAMINATION
EXAMINATION
INSPECTION Ictus cordis isn’t seen.
PALPATION Palpable (-), pulsus parasternal (-), sternal lift (-), pulsus epigastrium(-)
PERCUSSION • Lower right borderline of heart : ICS VI linea midclavicula dekstra
• Upper borderline of heart : ICS II linea parasternalis sinistra
• Waist of heart : ICS III linea midclavicular sinistra
• Lower left borderline of heart : ICS VII linea axilaris anterior sinistra

AUSCULTATION - Aortal valve : S1 & S2 standard, additional sound (-), reguler

- Pulmonary valve : S1 & S2 standard, additional sound (-), reguler
- Tricuspid valve : S1 & S2 standard, additional sound (-), reguler
- Mitral valve : S1 & S2 standard, additional sound (-), reguler
- Murmur : Murmur of the systolic phase of the mitral and tricuspid
valve
Murmur of the diastolic phase of the mitral valve
Interpretation : Cardiomegaly (Pancardiomegaly), Mitral
Stenosis,Mitral Regurgitation,Tricuspid Regurgitation
 ABDOMINAL EXAMINATION
Inspection : Simetrics, Striae (-), Enlargement of vena (-), Caput medusa (-), Spider nevi (-)
Auscultation : Peristaltic (+), Aorta abdominal bruit (-), A. Lienalis, A. femoralis (-)
Percussion : Flat (+), Dull (+) Shifting dullness (-) Undulation test (-), Liver dullness (-), Liver
span (-), traube space (-)
Palpation
• Superficial : Abdominal tenderness (-), Mass (-), muscular defense (-)
• Deep : Abdominal tenderness (-), hepatomegaly (-), splenomegaly (-)

Interpretation : Normal
 EXTREMITY EXAMINATION
Superior (D/S) Inferior (D/S)

Oedem -/- +/+

Pitting Oedema -/- -/-

Cold Extremity -/- -/-

Warm -/- -/-

Pain -/- -/-

Numbness -/- -/-

Capillary Refille <2s <2s

Interpretation :bilateral oedem lower exteremity

 02
ADDITIONAL
EXAMINATION
LABORATORY
 HEMATOLOGY EXAMINATION
(December 21th 2021 at 21.18 WIB)
EXAMINATION TEST RESULT NORMAL VALUE
Hemoglobin 11,5 (H) 11,7 – 15.5 g/dL
Hematocrit 35,5 33.0 - 45.0 %
Leukocyte 4,95 3.60 – 11,0 ribu/μL
Erythrocytes 3,4 3.8 - 5.2 juta/μL
Platelets 196 150 – 440 ribu/μL

Interpretation : Anemia
 HEMATOLOGY EXAMINATION
(December 21th 2021 at 21.18 WIB)
EXAMINATION TEST RESULT NORMAL VALUE
Eosinofil % 3,0 1.0 - 3.0 %
Basofil % 0.8 0-1%
Neutrofil % 58,7 50 – 70 %
Limfosit % 22.4 (L) 25 – 40 %
Monosit % 14,5(H) 2–8%
IG % 0.6 %
NLR (Neutrophil Lymphocyte Ratio) 2.6
ALC (Absolute Lymphocyte Count) 1110 /μL

Interpretation :, Lymphocytopenia,Monocytosis
 HEMATOLOGY EXAMINATION
(December 18th 2021 at 21.18 WIB)
EXAMINATION TEST RESULT NORMAL VALUE
MCV 103.5 (H) 80 – 100 fL
MCH 33.5 26 – 34 pg
MCHC 32.4 32 – 36 g/dL
Quantitative CRP 2.45 (H) ≤3 mg/L

Interpretation : MCV ↑
 HEMATOLOGY EXAMINATION
(November 24th 2021 at 21.18 WIB)
EXAMINATION TEST RESULT NORMAL VALUE
INR 1,68 (H) 0,59-1,10
INR (kontrol) 1,03 0,85-1,27

Interpretation :INR
 CLINICAL CHEMICAL TEST
(December 21th 2021 at 23:44 WIB)
EXAMINATION TEST RESULT NORMAL VALUE

Ureum 25 10 – 50 mg/dL
Creatinin 0.66 (H) 0.60 - 1.10 mg/dL
Uric Acid 6.6 2.6 – 5.7 U/L
Troponin I 35,4 20.0- 60.0 ng/L

Interpretation :Hyperuricemia
 ELECTROLYTE TEST
(December 30th 2021 at 12.25 WIB)
EXAMINATION TEST RESULT NORMAL VALUE

Natrium (Na) 130.0 (L) 135 - 147 mmol/L

Kalium (K) 3.20 (L) 3.5 – 5.0 mmol/L
Chlorida (Cl) 98.0 95 – 105 mmol/L
Calcium 8.3 (L) 8.8 – 10.8 mg/dL

Interpretation : Hyponatremia, Hypocalcemia, Hypocalemia

RADIOLOGY
X FOTO THORAX EXAMINATION
(September 26th 2021 at 09.01 WIB)
DESCRIPTION :
 Pulmo:
• The vascular pattern increases symmetrically
• No image of infiltrate
• Diaphragm at the left side seen as dim
 The left costophrenic angle seen as dim
 COR
• The apex shifts to the laterocaudal
• The waist of the heart is flattenin
• Double contour is seen
• The right border of heart is shift to the lateral right side

INTERPRETATION :
•Cor : Pancardiomegaly
•Pulmo : acute pulmonary edema, suspect left
pleural effusion
ELECTROCARDIOGRAP
HY (ECG)
 ELECTROCARDIOGRAPHY
(December 18th 2021 at 23.42 WIB)

Interpretation :
 ECG DESCRIPTION
● Rhytm : Atrial
● Regularity : Ireguler
● Frequency : 100x/minute
● P wave : difficult to examine
● PR Interval : difficult to examine
● QRS complex
Interval : 0,12 s
Axis : lead 1 (-), AvF (+) (LAD)
Transition zone : (-)
Q pathology : (-)
LVH : 10 + 8 = 18 mm  LVH (-)
(S of V1 + R of V6 ≥ 35 mm)
RVH : R / S of V6 <1, or R / S of V1> 1  RVH (-)
● T wave : T tall (-), T inverted (-), T flat (-)
● ST segment : normal

Interpretation : Atrial Fibrilation normo response, irregular, frequency 100x/min

 ELECTROCARDIOGRAPHY
(5th January 2022 at 23.50 WIB)

Interpretation :
 ECG DESCRIPTION
● Rhytm : Atrial
● Regularity : Ireguler
● Frequency : 90x/minute
● P wave : difficult to examine
● PR Interval : difficult to examine
● QRS complex
Interval : 0,12 s
Axis : lead 1 (-), AvF (+) (LAD)
Transition zone : (-)
Q pathology : (-)
LVH : 0 + 8 =8 mm  LVH (-)
(S of V1 + R of V6 ≥ 35 mm)
RVH : R / S of V6 <1, or R / S of V1> 1  RVH (-)
● T wave : T tall (-), T inverted (-), T flat (-)
● ST segment : normal

Interpretation : Atrial Fibrilation normo response, irregular, frequency 90x/min

ECHOCARDIOGRAPH
Y
 ECHOCARDIOGRAPHY
(October 19th 2021 at 10.19 WIB)

Interpretation : Segmental Hypokinetics, LV+RV systolic in good function, good systolic

RV function, dilatation LA + LV, moderate MR, severe MS,TR moderate, PH moderate
Wilkin score M:1 V:2 S:2 K:2 = 7, Specc (+) di LA
 DESCRIPTION OF ECHOCARDIOGRAPHY
• Heart chamber: enlarged in LA + LV
• LV wall : Thickened (-)
• Wall motion : hypokinetic anterior mid
apical
• Heart valve : moderate MR, severe
MS
moderate TR, moderate PH
• LV systolic function still in good
function EF 57%
INTERPRETATION:
• Segmental HypokineticsGood
LV+RV systolic in good function
• good systolic RV function
• dilatation LA + LV
• moderate MR, severe MS,TR
moderate,
PH moderate
 03
ABNORMAL DATA
 History Taking
1. Shortness of breath when lying down and improves in a
semi-sitting position (orthopneu)
2. Frequently waking up while sleeping at night (paroxysmal
nocturnal dyspneu)
3. Dyspnea on effort
4. History of same illness (+) in 2011
 Physical Examination
1. High respiratory rate (29x/minute)
2. Increasing JVP
3. Left tactile fremitus decrease
4. Lung basal wet crackles (-/+)
5. Enlargement entire of the heart border
6. Murmur of the systolic phase of mitral and tricuspid valve
7. Murmur of the diastolic phase of mitral valve

Laboratory Examination
1. Anemia 7. Hyponatremia
2. Lymphocytopenia 8. Hypocalcemia
3. Monocytosis 9. Hypocalemia
4. MCV
5. INR
6. Hyperuricemia
 ECG
Interpretation : Atrial Fibrilation normo response, irregular, frequency
100x/min
X Foto Thorax
Examination ECHOCARDIOGRAPHY:
1. Pancardiomegaly • Segmental HypokineticsGood
2. Acute pulmonary LV+RV systolic in good function
edema
• good systolic RV function
3. Suspect left pleural
• dilatation LA + LV
effusion
• moderate MR, severe MS,TR
moderate,
PH moderate
 04
PROBLEM LISTS
 PROBLEM LISTS
1. CHF
2. Pulmonal Hypertension
3. Bradicardi
4. Shock cardiogenic
5. Valvular Heart Disease
6. Atrial Fibrilation
7. Hyponatremia
8. Hypocalcemia
9. Hypocalemia
 CONGESTIVE HEART FAILURE
Assesment
• Etiology: VHD Ip Mx
• Fungsional: NYHA IV - Vital sign
• Anatomi: pancardiomegalyPO Bisoprolol 2,5mg 1x1
Ip Ex
• Bed rest/reducing activity shouldn’t get out of bed
Ip Dx • Take medication and control regularly
- BNP (≥ 35 pg/mL) • Low Phosphate, Protein and Salt Diet
- Pro-BNP (≥ 125 pg/mL) • Reduce water consumption

Ip Tx
Pharmacology
• Inj. Furosemide (20mg/2ml) 3x 1 amp/ 24 jam
If reach target :
• Inj. Digoxin (500mcg/2ml) 2x 1 amp /24 jam
• PO Spironolakton 1x25 mg - Amlodipin 10 mg 1x1
• PO Tolvaptan 15mg 1x1 - Captopril 25 mg 1x1
• PO Salbutamol 4mg 3x1
• PO Ramipril 2,5mg 1x1
 VALVULAR HEART DISEASE
Assessment
IP Ex :
• Prevent Tromboembolism
Bed Rest
disease Reduce activity

IP Dx :
• CHA2DS2-VASc = 2

IP Tx :
Warfarin 2 mg
Valve replacement

Ip Mx :
If reach target :
Vital sign - Amlodipin 10 mg 1x1
Echocardiography - Captopril 25 mg 1x1
INR (n = 2-3)
 ATRIAL FIBRILATION
• Assesment

Functional : EHRA IV
Classification : Normo Respone, First Diagnosted, AF Valvular
Complication : Stroke
• IP Dx:
? CHA-DS-VASc : 2
? HAS-BLEED : 0
? ECG
• IP Tx:

Farmacology IP Mx. = ECG, PT, Vital Sign,

INR (2-3)
PO Bioprolol 2,5mg 1x1
Warfarin 2mg/day 1x1 IP Ex. = Routine consumption drugs
 PULMONAL HYPERTENSION
Assesment
• Etiology: VHD,CHF,AF
Ip Dx Ip Ex
Pulmonary functional test • Bed rest/reducing activity shouldn’t get out of
BGA bed (leaning to wall/bed in 45°)
• Take medication and control regularly
Ip Tx • Low Phosphate, Protein and Salt Diet
Pharmacology • Reduce water consumption
PO Prostacyclin 20µg 1x1

Ip Mx
Vital sign
Congestive sign
 BRADYCARDIA
Assesment GCS
• Etiology: VHD,CHF,AF Ip Ex
• Complication: Shock Inform the condition of patient to patient’s family
Ip Dx
ECG

Ip Tx
Pharmacology
O2 nasal canule 3lpm
IV Atropine Sulfate (0,25mg/ml) 3x1 amp

Ip Mx
Vital sign
Sign of shock
 CARDIOGENIC SHOCK
Assesment Urine output
• Etiology: bradicardi
Ip Dx Ip Ex
ECG Inform the condition of patient to patient’s family

Ip Tx
Pharmacology
IV RL loading dose 250cc
IV Dobutamin 10mcg/kgbb
IV Norepinephrine 0,3 mcg/minutes

Ip Mx
Vital sign
Sign of shock
GCS
 HYPONATREMIA (130 mmol/L)
Assessment : 2 flabot, 1 flabot 62cc/jam
CHF  hypervolemic hyponatremia 1 flabot habis dalam 12 jam
Grading:
Mild: 130 – 134 mmol/L NaCl 0.9%
Moderate: 125 – 129 mmol/L Composition :
Severe: <125 mmol/L Na : 154 Mmol/L
Complication: metabolic acidosis Cl : 154 mmol/L

IP Dx : Ip Mx :
BGA Vital sign
Plasma osmolality Serum electrolytes
Urine routine Urine volume
If reach target :
- Amlodipin 10 mg 1x1
Ip Tx : Ip Ex :
Natrium correction - Captopril 25 mg 1x1
Restrict salt intake
(140-130) x 48 x 0,6 = 288 mmol/L Restrict oral fluid intake (1008-1152ml/ day)
1 flabot NaCl 0,9%  154mmol
 HYPOCALCEMIA (8.5 mg/dL)

Assessment : Ip Ex :
Complication : seizure, Heart failure Low Phosphate, Protein and Salt Diet (Poultry
product: Milk, egg)
IP Dx :
Urinalisis

Ip Tx :
Ca Gluconate 10% 1 amp diluted in 50ml D5%

Ip Mx :
Vital sign If reach target :
ECG
Potassium level on blood - Amlodipin 10 mg 1x1
- Captopril 25 mg 1x1
 Hypokalemia
• Assessment :
• Blood Kalium IP Mx :
• Vital sign
• EKG
IP Dx : • Blood Kalium
• EKG
IP Ex :
• Electrolite
• Dite High Kalium intake
(banana, grape, avocado, beans, potato)
IP Tx :
1. Defisit K : ∆K x BB x 0.8 =
2. ∆ K : Target kalium – Kalium pasien = 4 -3,2 = 0.8 x 4 x 0.8 = 25,6
3. KCl in 1 fl : 25 meq/fl 🡪 1 fl
4. KCl 20 meq PO/Day
5. KCl in 1 fl : 25 meq/fl 🡪 1 fl
THANK YOU
HYPOCALCEMIA – Ca Gluconate 10%
1 amp = 95 mg/mL Ca Gluconate
1 amp = 0.22 mmol/mL
1 amp = 10 mL
Initial dose : 1 – 2 amp Ca Gluconate diluted in 50 ml 5% Dextrose
infuse slowly in 5 min
Patient’s Ca = 8.5 mg/ dL = 184.7 mmol/L
Patient’s albumin = 2.775 g/dL = 27.75 g/L
Corrected Ca (mg/dL)=
Ca serum level (mg/dL) + 0.8 x [N Albumin – Patient’s Albumin
(g/dL)]
= 8.5 + 0.8 x (4 - 2.775)
= 8.5 + 0.8 x 1.225
= 8.5 + 0.98
= 9.48 mg/dL = 94.8 mg/mL = 1 ampul
Corrected Ca (mmol/L) =
Ca serum level (mmol/L) + 0.02 x [N Albumin – Patient’s Albumin
(g/L)]
= 184.7 + 0.02 x (40-27.75)
= 184.7 + 0.02 x 12.25
= 184.7 + 0.245
= 184.95 mmol/L = 0.184 mmol/mL = 1 ampul
CONGESTIV
E HEART
FAILURE
Diagnostic
Classification of Heart Failure
 Sign and
Symptoms of
HF
CHF types based on EF
 HFrEF
Management
ACE-I

ARB

BB CCB

sodium
and water
reabsorpt
ion -->
increased
IV fluid
volume
DIURETIC
Ramipril

BB Carvedilol
Mineralocorticoid receptor antagonist
(MRA)
Spironolactone
Advanced HF
RISK FACTOR AF
EDEM PULMO
DIURETIK
VALVULAR HEART
DISEASE
Warfarin - INR
VHD
Ejection Fraction in Mitral Regurgitation
>65% normal in compensated MR
50-65% mild impairment
40-50% moderate-severe impairment
<35% advanced impairment
As ejection fraction decreases operative risk increases.
 PULMONARY
HIPERTENSION
BRADYCARDIA
CARDIOGENIC SHOCK
HYPONATREMI
A
Hyponatremia
Hyponatremia
HIPERCHLOREMI
A
Hyperchloremia
HYPERCREATINEMI
A
Hypercreatininemia
HYPOCALCIUM
151
152
153
Calcium
Calcium
JAAZAKUMULLAH