Department of Internal Medicine

Faculty of Medicine Sultan Agung Islamic University

2021

Case Based Discussion

Advisor :
dr. H. M. SAUGI ABDUH, Sp.PD., KKV, FINASIM

By :
Aldian Mahendra J
30101700012
 Patient Identity

? Name: Mrs. W
? Patient ID: 01-43-96-84
? Age: 82 years
? Sex: female
? Religion: Moslem
? Address: Tenggang, Gayamsari, Semarang
? Date in Hospital : November, 15 2021
? Date of Examination: November, 20 2021
? Class: BPJS Non-PBI
 History taking (Autoanamnesis)
Main Complaint
• Abdominal Pain

History of present illness

• Patient came to ICU of Sultan Agung Islamic Hospital 15 Nov 2021
complaining Abdominal Pain from 1 days ago in Hypogastic region,
she also said that she has Constipation 1 weeks ago until now and
complaint dyspnea. Patient just lyling in bed and doesn't want to eat or
drink. Patient has other Manifestation like Water Vomiting, dry cough
and low back pain, she has history of Cardiac disease before
HISTORY OF ILLNESS
HISTORY OF PREVIOUS ILLNESS
SOSIO-ECONOMIC
Heart Disease History (+)
HISTORY :
Same Illnes (+)
Hospital cost certified by
Hypertention history (+)
“BPJS NON PBI”
Passive Smoking (+)
Stroke (-) FAMILY’S HISTORY OF DISEASE
TB (-) Hypertension history (+) Husband
DM history (-) Heart Disease History (-)
Dyspnea (-)
 VITAL SIGN (20 November 2021)

General : Composmentis
Awareness : E4M6V5 (GCS : 15)

Vital Sign
• Blood Pressure : 152/86 mmHg
• Pulse : 97x/menit
• Breath Frequency : 21 x/minute

• Temp : 36,3 oC
• SpO2 : 99%
Intepretation : Normal
GENERAL
EXAMINATION
• Head : Mesocephal, alopesia (-)
• Eyes : Anemic Conjungtiva (+/+), Icteric sclera(-/-)
• Nose : secret (-), Nostril Breath (-)
• Ears : Normal Shape, discharge (-/-)
• Esophagus : Hyperemic (-), pain devour (-)
• Mouth : Cyanosis (-)
• Neck : Trakhea deviation (-), Lymph Hypertropy (-), Increasing

JVP (-)

Interpretation :
Anemia
 Lung examination
INSPEKSI ANTERIOR POSTERIOR

Static RR : 21x/min, Hyper pigment (-), ICS Normal, RR : 21x/min, Hyper pigment (-)
Diameter AP > LL ICS Normal, Diameter AP > LL

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

Palpation Palpable pain(-), tumor (-), Arcus costae angle < Palpable pain (-), tumor (-), Arcus costae angle < 90 0,
900, enlargement of ICS (-), Stem fremitus normal enlargement of ICS (-), Stem fremitus Normal

Percution Hiper Sonor Hiper Sonor

Auskultation Whezzing (-), Ronchi (-) Whezzing (-), Ronchi (-)

Interpretations: Normal
 CARDIAC EXAMINATION
INSPECTION Ictus cordis isn’t seen.
PALPATION thrill (-), pulsus parasternal (-), sternal lift (-), pulsus epigastrium(-)
PERCUSSION •Upper borderline of heart     : ICS II left sternal line
•Waist of heart    : ICS III left parasternal line
•Lower right borderline of heart  : ICS V linea sternalis dextra 
•Lower left borderline of heart    : ICS VI 2 cm to the medial
linea Midclavicularis Sinistra
AUSCULTATION
• Aortal valve    :  S1 & S2 standard, additional sound (-) 
• Pulmonary valve  :  S1 & S2 standard, additional sound (-) 
• Tricuspid valve     :  S1 & S2 Systolic Murmur
• Mitral valve    :  S1 & S2 standard, additional sound (-) 

Interpretation : Cardiomegaly (LVH) Trikuspidal Regurgitation

 ABDOMEN EXAMINATION (20 Nov 2021)
INSPECTION symetric, distended (-), sycatric (-), striae (-), enlargement of
vena (-), caput medusa (-), hiperpigmetation skin (-)
Auscultation Peristaltic Decrease (+)
abdominal aorta bruits (-) splenic artery (-) femoral artery (-)
Palpation •Superfisial    : mass (-), Hypogastric pain (+),
•Deep     : Hypogastric pain (+), liver normal, spleen and
kidney weren’t palpable,
•Murphy’s sign (-)

Percussion  shifting dullness (-)

•Liver    : deaf  (+), right liver span 11 cm, left liver span 6 cm
•Spleen    : Traube space percussion 🡪 tympani

Interpretation : Abdominal Pain

EXTREMITY EXAMINATION
SUPERIOR (D/S) INFERIOR (D/S)
Oedem -/- -/-
Wound -/- -/-
Cyanotic -/- -/-
Cold Extremity -/- -/-
Capillary Refille <2 s <2 s
Clubbing Finger -/- -/-

Intepretation : Normal
Laboratorium Examination
 Laboratory ( 15 Nov 2021 )
TEST RESULT NORMAL RESULT
Hematology
Hb 9,8 (L) 11.7-15.5 g/dL
Hematocrit 28 (L) 33-45 %
Leukocyte 23,79 (H) 3.6-11.0
Trombocyte 255 150-440

PPT
PT 12,1 (H) 9,3- 11,4 s
PT (Kontrol) 11,3 9,3 – 12,7 s

APPT
APTT 27,2 21,8 - 28,4 s
APPT (Kontrol) 26,8 21,2 – 28,6 s

Clinical Chemical
Random Blood Sugar 133 75 – 110 mg/dL
Ureum 86 (H) 10 – 50 mg/dL
Creatinin 0,79 0,60 – 1,10 mg/dL
 TEST RESULT NORMAL RESULT
Albumin- Globulin
Albumin 4,1 3,4-4,8 gr/dL
Globulin 3.97 3,4-4.8 gr/dL
Total Protein 5.8 6-9 gr/dL
Elektrolit 17/11/21 19/11/21
Natrium (Na) 130 (L) 127 (L) 135 – 147 mg/dL
Kalium (K) 2.70 (L) 2.50 (L) 3.5 – 5.0 mg/dL
Klorida (Cl) 111 (H) 97.0 95 – 105 mg/dL
Calcium 8.9 8.8-10.8 mg/dL

Interpretation
• Anemia
• Hiponatremi
• Hipokalium
• Leukositosis
• Ureum Increase
ECG
Examination
15/11/21
 Interpretation
? Rhytm : Asinus
? Regularitas : Irreguler
? Frekuensi : 75 x/menit
? Axis : LAD
? Zona Transition : V3
? P Wave : Sulit Dinilai
? Interval PR : Sulit dinilai
? QRS Complex : 0,08 second
? Q wave : -
? Segmen ST : -
? LVH : -
? RVH :-
? Gelombang T :-
? T Flat :-

Interpretation : AF Normo Respone

Examination
18/11/21
 Interpretation
? Rhytm : Asinus
? Regularitas : Irreguler
? Frekuensi : 75 x/menit
? Axis : LAD
? Zona Transition :-
? P Wave : Sulit Dinilai
? Interval PR : Sulit dinilai
? QRS Complex : 0,08 second
? Q wave : -
? Segmen ST : -
? LVH : -
? RVH :-
? Gelombang T :-
? T Inverted : II,III,Avf,V1,V2
? Other : RBBB

Interpretation : AF Normo Respone, Ischemia Anteroinferior with RBBB

Chest X-Ray Examination
14/11/21
Interpretation :

Cor tampak membesar kearah laterocaudal

Sela Iga melebar
Elangatio Aorta
Jantung Pendulum
Corakan Bronkovaskular Normal
Diagfragma Letak rendah

Kesan :
- Cardiomegaly
- Emfisema
 Examination
Echocardiography 16/11/21
ECHOCARDIOGRAPHY
Dimensi ruang jantung: Tidak membesar
dinding LV: Tidak Menebal
Wall Motion: Global Normokinetik
Katup Jantung: TR moderate, PH moderate
Fungsi LV sistolik baik EF 65%
Fungsi RV Sistolik Baik TAPSE 40 mm Fungsi LV
Diastolik baik E/A >1

Kesan:
Global Normokinetik, Fungsi LV+RV sistolik baik, Fungsi LV Diastolik Baik,
TR Moderate, PH Moderate
 Examination
15/11/21

Tampak Distensi usus besar Kesan :

Tampak multiple air fluid level pendek bertingkat LBO Susp. Volvulus
Tampak Skoliosis lumbalis dengan konveksitas ke kanan Skoliosis Lumbalis dengan konveksitas
Corpus L1,2 lebih pipih ke kanan
Abnormal Data

History Taking
1. Abdominal Pain
2. Constipation
3. Dypsnea Physical Examination

4. Dry Cough 1. Cardiomegaly

5. Water Vomiting 2. Anemia

6. Low Back Pain

7. History of Cardiac Disease
(Susp. CHF)
8. Hypertension
 Abnormal Data Chest X-Ray:
1. Cardiomegaly

ECG : 2. HHD
Lab 3. COPD
AF Normo Sinus
1. Anemia
2. Leukositosis
3. Hiponatremi
4. Hipokalium
5. Ureum Increase
Abdomen X-Ray:
Echocardiography : 1. Volvulus Sigmoid
• TR Moderate
• PH Moderate
 Problem List

• Heart Failure • COPD

• AF Normo Respone • Anemia
• Hypertension G1 • Hyponatremia
• VHD • Hypokalemia
• Volvulus Sigmoid
 Heart failure
Assessment
• Non Pharmacology
Anatomi: Cardiomegaly (LVH)
Low fat intake
Functional: NYHA II
Reduce activity
Etiology: Hypertension, HHD, VHD
LVEF 65% 🡪 heart failure with Low salt intake
HF Preserved ejection fraction (HFpEF) Low potassium intake 
IP. Mx :
IP. Dx
Vital sign, EGC, Renal Function,
EKG
BNP (Brain natriuretic peptide) IP. EX
Echocardiography - Low Phosphate, Protein and Salt Diet
Chest X ray - Reduce water consumption
- Bed Rest/Restriction of physical activity
IP. Tx :
- Reducing Emotional stress
• Bisoprolol 1x 2,5 mg
• Captopril 1x12,5 mg - Routine drugs consumption
 Atrial Fibrilation

?Assesment

Functional : EHRA II
Classification : Normo Respone, First Diagnosted, AF Valvular
Complication : Stroke
?IP Dx:
?CHA-DS-VASc : 5

?HAS-BLEED : 3
IP Mx. = ECG, PT, Vital Sign,
?EKG INR (2-3)

?IP Tx:
Farmacology IP Ex. = Routine consumption drugs
Bisoprolol 1x2,5mg
Warfarin 2mg/day 1x1
Assesment
Stage 1 Hipertension
• LVH, Valvular Disease, HF, HHD
Modified : Passive Smoking
Non-Modified : Age>60, Female (Menopause)
Complication : Heart Failure, Aritmia
Ip Mx
Ip Dx - Vital sign
- BMI
- Lipid profile (LDL, HDL, TG, cholestrol total)
- uric acid Ip Ex
- Waist Circumference • Bed Rest/Restriction of
- Glucose Level physical activity
• Reducing emotional stress
Ip Tx • Taking drugs regularly
Pharmacology • Reduce cholesterol
• Captopril tab 12,5 mg 2x1
Non pharmacology
• Low salt intake (<2gr/day)
• Reducing weight towards an ideal body
• Eat a healthy balanced diet (containing vegetables, fruits, low-fat dairy products,
wholegrains, fish)
• Low consumption of saturated fatty
• Regular aerobic exercise (eg. Walking,, swimming,cycling) on 2-3 / 5-7 days per
week
 Valvular Heart Disease
Assessment
Prevent thromboembolism disease, PAD, ACS
TR Moderate, PH Moderate

IP. Dx
EKG
CHAD2 VASC Score = 5

IP. Tx :
Bisoprolol 1x 2,5mg
Valve Surgery

IP. Mx :
Vital sign
Echocardiography

IP. EX
Bed rest and Reduce activity
 Clinical COPD

Assessment
Risk Factor : Passive Smoker
IP Diagnosis

- Spiromerty FEV1/FCV < 70%

- Kortikosteroid Test

- BGA (VEP1<40%)
IP Teraphy
Pharmacology
Budesonide 3mg 1x1 PO
Formoterol 12mcg/puff. Puff 2

IP Monitor
• Vital Sign
 Anemia
? Assessment
? Chronic Heart Failure
? Sign of anemia
? Types of anemia: IP. Mx :
- anemia microcytic hypochromic Vital sign
- anemia normocytic normochromic
Hema routine test
? IP. Dx
? Reticulocyte count IP. EX
? Peripheral blood smear: burr cell
Consumption high iron diet
IP. Tx :
Ferrous sulfat 3x200
Vit. C
 Hyponatremia
• Assessment : • Ip Tx :
• Natrium correction
• HF 🡪 hypervolemic hyponatremia • (140-124) x 50 x 0,6 = 480 mmol/L
• Grading: • 1 flabot NaCl 3% 🡪 513 mmol
• 1 flabot, 1 flabot 62cc/jam
• Mild: 130 – 134 mmol/L • 1 flabot habis dalam 12 jam
• Moderate: 125 – 129 mmol/L
• NaCl 3%
• Severe: <125 mmol/L • Composition :
• Complication: metabolic acidosis • Na : 513 Mmol/L
• Cl : 513 mmol/L

• IP Dx : • Ip Mx :
• Vital sign
• BGA
• Serum electrolytes
• Electrolyte level • Urine volume

• Ip Ex :
• Restrict salt intake
• Restrict oral fluid intake (1302-1488ml/ day)
 Hypokalemia
• Assessment : • Ip Tx :
Defisit K : ∆K x BB x 0.8 = 1 x 49 x 0.8 =39,2
• Blood Kalium
∆ K : Target kalium – Kalium pasien = 3.5 -2,5 = 1

• IP Dx : KCl in 1 fl : 25 meq/fl 🡪 1 fl
KCl 20 meq PO/Day
• EKG
• Electrolite • Ip Mx :
• Vital sign
• EKG
• Blood Kalium

• Ip Ex :
• Dite High Kalium intake
(banana, grape, avocado, beans, potato)
 Koreksi Kalium

1 mEq/L : 200 meqs

25 ml = 1mEq/ml
1 fl (500cc) : 20mEq
 Volvulus Sigmoid
? Assesment
?Etiology : Malrotation
?Dd : Volvulus Cecal, Cancer
?Risk Factor :Colon Abnormality Anatomy, Constipation, Age>60
?Complication : Peritonitis, Sepsis, Strangulation

? IP Dx:
?FPA, Colonoscopy, Endoscopy, Biopsi
• IP Mx:
• Vital Sign
? IP Tx:
• Elektrolit
• Urin Output
Farmacology
• IP Ex:
Inj. RL 20 tpm • Explain about the disease
• Water Intake
Consult Surgeon
Volvulus Sigmoid
Atrial Fibrilation
RISK FACTOR AF
Heart Failure
European Heart Journal (2016)
The Power of PowerPoint | 81
The Power of PowerPoint | 82
The Power of PowerPoint | 83
Valvular Heart Disease
Hypertensive Heart Disease
COPD
Risk
Factor
ANEMIA
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108
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