Case Based Discussion (CBD)

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

oleh :
DEWI AJENG R
30101206611
 Name : Mr. d

 Medical Record : 01184548

 Age : 57 years old

 Gender : Male

 Religion : Moslem

 Job : Wiraswasta

 Address : Cabean, Demak

 Room : Baitul Izzah 2

 Entry date : 25 December 2016

HISTORY TAKING

Main Complain

Chest pain
History of present ilness
Patient came into the Clinic Room of Islamic Hospital of Sultan Agung
Semarang complained about her disease, she felt chest pain about 3 days
ago. This complaint was happened for manny times. Especially when she
activity , the complaint will be better if she got a rest . 1 day before entry to
the hostpital ,she complain chest pain without activity . She also felt cough
for 1 week.

Patients don’t have a history of diabetes. Patient got health assurance from
JKN PBI
Main Problems : chest pain
Onset : 3 days before came to hospital
Chronology :
He complained about 3 days ago she gets chest pain , and the complaint
happen when and without activity.
Quality and Quantity : patient felt chest pain when and without activity
Modification factor : Patient will be better if she got a rest
Comorbid complains : chest pain, cough
HISTORY OF PREVIOUS ILLNESS SOSIO-ECONOMIC HISTORY :
Hypertension history (+) Hospital cost certified by
DM history (-) JKN PBI
Asthma history (-)
Alergy history (-)
Smoking (+)
Alcohol (-)

FAMILY’S HISTORY OF DISEASE

Hypertension history (+)

DM history (-)

Asthma history (-)

Physical Examination

 General : weakness
 Awareness : composmentis
◦ Antropometri Status
Height = 155 cm dan Weight = 80kg
BMI = BB(kg)/TB²(m²) =80 kg/(1,55 m)²
=80/2,40
=
 Vital Sign
• Blood Pressure : 115/70 mmHg
• Heart Rate : 84x/menit
• Respiration Rate : 24x/menit
• Temperature : 36.8o C
General : Patient looks weakness
Skin : itching (-), redness (-), jaundice (-), pale (-), slick (-), turgor skin (-)
Head : headache (-), dizzy (-)
Eyes : blurred vision (-), red eyes (-), icteric sclera (-/-), konjuntiva pale (-)
Ears : hearing loss (-), ring (-), discharge (-)
Nose : septum deviation (-) nosebleed (-), discharge (-), nostril breath (-)
Mouth : cyanosis (-), thrush (-), bleeding gums (-)
Throat : pain swallow (-), hoarseness (-), difficult in swallowing (-)
Neck : enlargement of the gland (-), dilatation vein (+), Jugular vein prressure
3 cm
Chest : cough (+), sputum (-), blood (-)
Cardiac : chest pain (+), palpitations (-), dypneu (-)
Digestive : abdominal pain (-), nausea (-), vomiting (-)
Musculoske : weak (-), rigid (-), lower back pain (-)
Extremity : oedem upper/lower extremity (-)

Intepretation : weakness, chest pain, dilatation vein of the neck,

cough, JVP increased
 LUNG EXAMINATION
INSPECTION ANTERIOR POSTERIOR

Static RR : 20x/min, Hyper pigment (-), spider nevi RR : 21x/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 (-), Stem fremitus (=) Palpable pain (-), tumor (-), Stem
fremitus (=)

Percution Faint (-) Faint (-)

Auskultation Whezzing (-), Ronchi basah basal (+) Whezzing (-), Ronchi basah basal (-)

Intepretation : Ronkhi basal

COR EXAMINATION
• Inspection : Ictus cordis seen.

• Palpation : Ictus cordis is palpable at ICS VI, from linea

axillaris anterior sinistra ICS 2 to medial, thrill (-),
pulsus epigastrium (-), pulsus parasternal (-), sternal lift (-)

• Percussion : Faint

 Upper borderline : ICS II left parasternal line

 Waist
 Lower right borderline
medial
 Lower left borderline
shift to lateral
: ICS III left parasternal line
: ICS IV right sternal line 1cm shift to
: ICS IV from left midclavicula line 2cm

Intepretation : Ictus Cordis seen, left ventrikel hypertrophy,

right ventrikel hypertrophy
 COR EXAMINATION
• 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

Intepretation : Normal
 Abdominal Examination
 Inspection : sycatric (-), striae (-), enlargement of vena (-), caput
medusa (-), spider nevi (-)
 Auskultasi : peristaltic sound (+)  12 x / minutes
 Percussion : timpani, shifting dullness (-), liver
span : dextra 11cm, sinistra 6 cm, traube space (+),
left CVA pain (- ) right CVA pain (-)
 Palpation : Superfisial : defence muscular (-) mass (-),
hepatomegali (-), Murphy’s sign (-)
Profunda : Pain  kidney (-) lien (-) hepar
isn’t palpable, splenomegali (-)

Intepretation : Normal
Extremitas
Extremitas Superior Inferior
Oedem -/- -/-
Cold palms -/- -/-

Fisiologis Reflex +/+ +/+

Patologis Reflex -/- -/-

Sensibility +/+ +/+

Ulkus -/- -/-

Intepretation : -
LAB Examination
 Intepretasi :
- leukositosis
- Azotemia
- Hipoalbuminemia
- Peningkatan Transaminase
- Hiponatremi
ELECTROCARDIOGRAPHY
Interpretation
• Rhytm : sinus
• Regularitas : reguler
• Frekuensi : 115 x/menit
• Axis : lead 1 = +; AvF = +  NAD
• Zona Transisi : V3
• Gelombang P : tinggi 0,1mv lebar 0,04ms
• Interval PR : 0,12ms
• Komplek QRS : v5-v6 0,08 detik (normal)
• Gelombang Q : normal
• Segmen ST : normal
• Gelombang T : T inverted pada V4,V5,V6
• LVH : R di V5+ S di V1 >35
• 28+17=45 kotak kecil

Kesan :LVH, Sinus takikardi dengan iskemik lateral,

Echocardiography
Interpretation
Foto Thoraks

Interpretation :
Cor : Cardiomegali (LV,LA,RV)
Elongatio Aorta
Pulmo : tak tampak kelainan
 ABNORMALITY DATA

Anamnesis : Physical Pemeriksaan

Examination: Penunjang:

1. Chest pain 8. EKG : LVH,

2. Weeknes 1. Ronkhi basal sinus takikardi
pulmo with iskemik
3. Cough 2. Ictus Cordis lateral
Seen 9. Laboratory :
3. Dilatation Vein - leukositosis
of the Neck - azotemia
4. Right ventrikel - Hipoalbummin
hypertrophy emia
5. Left ventrikel - Peningkatan
hypertrophy Transaminase
- Hiponatremi
 Echocardiography :
- Global Hypokinetik
- Fungsi sistolik LV
menurun dengan LVEF Foto Thoraks:
20% - Cor Cardiomegali
- Disfungsi diastolik grade - Elongatio aorta
I - Pulmo : tak tampak
- Fungsi sistolik RV kelainan
menurun
- MR moderate, AR mild
- Sugestif DCM
 Problem List

1. CHF
2. CKD
3. Azotemia
4. Hipoalbuminemia
5. Peningkatan Transaminase
6. Hiponatremi
7. IHD
• Ass :
• Anatomi : LVH,RVH
• Fungsional : NYHA IV
• Etiologi
• EKG : IHD
• ECHO : valvular heart disease
DCM
• IP Dx :
- angiografi coroner
- enzym jantung : CKMB, troponin
• Ip Tx :
o Injeksi Furosemide 2x1 amp (20mg)
o Digoxin 2x0,125 mg
o Captopril 3x6,25 mg
o Lactulosa syr 1C
• IPMx : Vital Sign, Echocardiography, Electrocardiogram
• IPEx :
o Bed Rest/ Restriction of physical activity
o Sodium and fluid restriction
o Reducing emotional stress
o Sit position or a half sleep position
o Low fat intake
o Low salt intake
o High fiber diet
• Ass :
• DM
• Asidosis metabolik
• Oedem pulmo
• Kejang
• HT Emergency
• Bleeding
• Hiperkalemia
• Infeksi
• IP Dx :
• Blood gas analysis
• USG renal
• Biopsi
• GDS, GDP, GD2PP, HbA1C
• Vital sign
• IPTx : Inj. Furosemide 3x10 mg
• IPMx :
• KU
• Vital sign
• Hitung LFG
• Balance cairan
• IPEx : Pembatasan konsumsi garam dan air, istirahat
yang cukup
• LFG : (140-umur)xBB 0,85
72x1,21
: 47,68  grade 3 ( Evaluasi dan Terapi
komplikasi )
• Ass : CKD
• IP Dx :
• Analisis darah dan urin
• Index Rasio BUN ( Blood Ureum Nitrogen )
• Ip Tx :

Non pharmacology :

- Diet tinggi kalori dan

rendah protein
- pembatasan konsumsi
kalium dan garam

• IpMx : - Lab ureum creatinin

• IpEx : - cek ureum creatinin rutin
- Tidak melakukan aktfitas berat
- Istirahat cukup dan minum obat teratur
• Ass :-
• IP Dx :-
• Ip Tx :
- koreksi albumin
- 4-ALBUMIN X 55(BB) X 0,8
- (4-3,33) = 29,48
- KONSENTRASI ALBUMIN 100 ML KADAR 25% =25
ML ALBUMIN
- Plasbumin 20% DALAM 100 ML = 20 ML ALBUMIN
- albumin 20 dalam 50ML = 10 mL albumin

• IpMx : albumin (kimia darah)

• IpEx : Diit tinggi protein
• Ass :
 NASH
 Penyakit Hati Kronis
• IP Dx :
 USG Abdomen
 Biopsi
• Ip Tx :
 Farmakologi : Vit E, Ursodeoxycolic acid (UDCA)
• IpMx :
 liver function Test
 BMI
 KU
• IpEx :
• control weight, avoid smoking and alcohol, do not eat
fatty foods
• Ass :-
• IP Dx :-
• Ip Tx :
Non farmakologi :
- Diet cairan
Farmakologi :
Koreksi na+ dengan kecepatan koreksi 0,5-1 meq/l/jam.
(140-130,1)x 55 x 0,6 =326,7
KOMPOSISI:
NA: 154 Mmol/L
Cl: 154 mmol/L
2 flask
• IpMx :
• elektrolit
• IpEx :
• Avoid type of drugs that can affect natrium decrease
• Ass :
o Komplikasi :
 Ekstrasistol ventrikel
 Infark miokard
 Takikardi
 Syok kardiogenik
 Gagal jantung kongestif
 Perikarditis
o Etiologi :
 Angina pectoris
 Sindrom koroner akut
• IP Dx :
 EKG
 Vital sign
 Foto thoraks
• Ip Tx : Nitrocaf Retrat 2 x 2,5 mg
• IpMx :
 TTV
 EKG
• IpEx :
• control weight, avoid smoking and alcohol, do not eat
fatty foods