CASE BASED DISSCUSION

ALFI MARITA TRISTIARTI

(01.207.5440)

ADVISOR
dr. M. Saugi Abduh, Sp.PD
PATIENT IDENTITY
Name : Mrs. M

Age : 61 years old

Gender : Female
Religion : Moslem
Address : Semarang
Room : Baitur Rijjal
Check in date : 6 July 2012

Check out date : 11 July 2012

 HISTORY TALKING
HEMATEMESIS

• Vomiting blood + 2 days ago

• Abdomen circumference getting bigger day to day, + 2 month ago
• Swelling in lower extremity
• Fever (+)
• Wakeful (+)

History of previous illness

• Hypertension (+)
• Liver disease (-)
• Kidney disease (-)
• Diabetes mellitus (-)

Family history of disease (-)

Social economic history

• Free clinic
 Systemic Anamnesis
General : edema(+)
Skin : itching (-), jaundice (-), pale (-)
Head : headache (-)
Eyes : blurred vision (-), red eyes (-), jaundice sclera (+/+)
Ears : hearing loss (-), discharge (-)
Nose : nosebleed (-), discharge (-)
Mouth : cyanosis (-), thrush (-)
Throat : pain swallow (-), hoarseness (-), difficult in swallowing (-)
Neck : trachea deviation (-), lymph hypertrophy (-)
Chest : dyspnoea (+), cough (-), sputum (-), blood (-)
Cardiac : chest pain (-), palpitations (-)
Digestive : nausea (+), vomiting (+), defecate / miction (+/+)
Muscular : stiff neck (-), back pain (-)
Extremity : edema of lower extremity (+), edema of upper extremity (-)
 PHYSICAL EXAMINATION
General • dyspnea (+)
Awareness • Compos mentis
Nutrient state • Weight = 53 kg; Height = 156 cm
BMI • 53 / (1,56)² = 21.3 (normoweight)
• TD 120/60 mmHg
• HR 96/menit
Vital Sign
• RR 32 X/m
• T 36,5 C
Head • Mesocephal, alopesia (-)
Eyes • Anemic Conjuntival (-/-), Jaundice Sclera(+/+)
Nose • Secret (-), Nostril Breath (-)
Ears • Normal Shape, Discharge (-/-)
Throat • Hyperemic (-), Pain Devour (-)
Mouth • Cyanosis (-), Dry Lips (-),
Neck • Trachea Deviation (+), Lymph Hypertrophy (-)
Extremity • edema of lower extremity (+)
Interpretation : dyspnea, oedem extremity
 THORAX - PULMONARY
INSPEKSI ANTERIOR
Static RR : 32x/min, Hiperpigmentation
(-), spider nevi (-), atrofi M.
Pectoralis (-), Hemithoraks S=D,
ICS extend (-), Diameter AP < LL
Dinamic Up and down of hemitoraks
S=D, muscle retraction of
breathing (-), retraction ICS (-)
Palpation Palpation pain (-), tumor (-),
enlargement of ICS (-), Stem
fremitus D=S
Percution Sinistra sonor
Auskultation Vesicular(+), ronchi (-),
wheezing (-)
POSTERIOR
RR : 32 x/min, Hiperpigmentation
(-), spider nevi (-), Hemithoraks
Hemithoraks S=D, ICS extend (-),
Diameter AP < LL
Up and down of hemitoraks S=D,
muscle retraction of breathing (-),
retraction ICS (-)
Palpation pain (-), tumor (-),
enlargement of ICS (-), Stem
fremitus D=S
Sinistra sonor
Vesicular(+), ronchi (-), wheezing
(-)
 THORAX - COR
• Inspection : Ictus cordis isn’t seen.
• Palpation : Ictus cordis is palpable in ICS VI linea mid clavicula sinistra,
thrill (-).
• Percussion : hiposonor (dull) sound
• Upper borderline of heart : ICS II linea sternalis sinistra
• Waist of heart : ICS II linea parasternalis sinistra
• Lower right borderline of heart : ICS VI linea parasternalis dextra
• Lower left borderline of heart : ICS VI lateral linea mid clavicula
sinistra
• Auscultation :
• Katup aorta : SD I-II murni, reguler, AI<A2
• Katup trikuspid : SD I-II murni, reguler, T1>T2
• Katup pulmonal : SD I-II murni, reguler, P1<P2
• Katup mitral : SD I-II murni, reguler, M1>M2
• Addition sound : (-)

Interpretation : cardiomegali
 ABDOMEN
• Inspection : convex of surface(+), cycatric(-), striae(-),
caput medusa (-).
• Auscultation : peristaltic (+) N
• Percution : dull (+), shifting dullness (+)
• Palpation
• Superficial : massa (-)
• Deeper : abdominal pain (-), hepar, lien isn’t palpable,
renal isn’t palpable

Interpretation: ascites (+)

 Extremities

Extremities superior inferior

- edema -/- +/+
- cold -/- -/-
- reflect physiologist +/+ +/+
- Icteric -/- -/-
 LABORATORY

06/07/2012 Hematology Total Bilirubin 3,25

Haemoglobin 4,8 g/dl Direct Bilirubin 2,38
Ht 16,8 % Indirect Bilirubin 0,87
Leukocyte 4.10 3/uL Total Protein 5,64
Platelet 83.103/uL Albumine 2,30
Random blood 109 mg/dl Globulin 3,34
glucose
AST 33
cholesterol 63 mg/dl
ALT 16
Triglyceride 58 mg/dl
HbSAg (-)
Uric Acid 12,8 mg/dl
Urea 62 mg/dl
Creatinine 0,91 LFG = 52 ml/menit/1,73 m2

Anemia, trombositopenia, hiperbilirubin,

hipoalbumin, hyperuricemia, uremia
ECG
1. Rhythm : irregular
2. Heart Rate : 1500/20 = 75 x/minute
3. Axis : NAD (Normo Axis Deviation)
4. Transitional Zone : (-)
5. Morphology :
- P wave : disappear
- Interval PR :-
- QRS complex : Normal (0,08 second)
- ST segment : elevation (-) depression (-)
- T wave : Inverted (-) T tall (-)

Interpretation : Atrial Fibrilation, lateral ischemic

RADIOLOGY

• Cardiomegali
• Calsification
arcus aorta
 Abnormal Data
Advance
Anamnesis :
Physic Examination : Examination:
• hematemesis -Laboratory :
• Ascites •Hearth : cardiomegali (Lower trombositopenia,
• dyspnea right borderline of heart and hiperuricemia
hyperbilirubine,
• Edema Lower left borderline of heart) hypoalbumine
extremity •Abdomen :
-ECG : Atrial
• Shifting dullness (+)  Fibrilation rapid
ascites frequence

-Ro :
cardiomegali,
elongatio aorta arc
 PROBLEM LIST
1. CHIROSIS HEPAR
2. ASCITES
3. ANEMIA
4. TROMBOSITEMIA
5. HYPERBILIRUBINE
6. HYPOALBUMINEMIA
7. HYPERURICEMIA
8. UREMIA
9. HIPERTENSI GR I
10. ATRIAL FIBRILASI
11. LATERAL ISCHEMIC
 CHIRROSIS HEPAR
ASSESMENT Compensation and decompensation

IP DX Biomarker for Viral Hepatitis

Imaging : USG or MRI
IP TX - Diet : protein 1 g/Kg Weight, calories : 2000-
3000 kcal
- Curcuma 2x200 mg
- Transplantation

IP MX 2) Vital Sign 4) Observation complete blood

count, renal
Liver function test
IP EX 1) Bed rest 2) Diet Low Salt
 ASCITES
ASSESMENT Transudate and exudate

IP DX Imaging : USG
Paracentesis = Culture
Rivalta test
IP TX - Pharmacology : loop diuretics: furosemide
- Anti aldosterone: spironolacton 2 – 3x 100 mg
- Beta blocker: propranolol

IP MX careful monitoring of electrolytes, albumin

serum,
Circumference of abdomen, weight
IP EX 1) Bed rest 2) restricted fluid and diet Low salt
 ANEMIA
ASSESMENT Makrocytic , normocytic normochromic,
mikrositik hypochromic
IP DX 1) Laboratory : eritrocyte and reticulosite
index, 2) bone marrow punction
IP TX Transfussion PRC
IP MX 1) Vital sign 2) complication of tranfussion
IP EX 1) Education about the disease, 2)
complication post transfussion
 TROMBOSITOPENIA
ASSESME Disfunction of platelet secretion, over
NT distruction, abnormality distribution
IP DX 1)Peripheral smear 2) bone marrow punction
IP TX - Trombocyte exchange therapy
- Treatment the basically disease
IP MX 1) Blood count 2) monitoring syock
IP EX Education what the disease
 HYPERBILIRUBINEMIA
ASSESMENT Pre hepatik, intra hepatik, post hepatik
IP DX Imaging (sonographi, CT, MRI, endoscopic
Retrograde Cholangio Pancreatgraphy)
Byopsi
IP TX - Treatment basically disease
IP MX Bilirubine serum
IP EX Separate dining
 HYPOALBUMINEMIA
ASSESMENT -
IP DX -
IP TX Exogenous albumin 20% dalam 100cc 2
20% dalam 50 cc 1
IP MX Albumin serum
IP EX Specific dietary recommendations are based
on the underlying disease
 HYPERURICEMIA
ASSESMENT -

IP DX -
IP TX - Allupurinol (Gout) : NSAIDs
- Treatment for basically disease

IP MX serum uric acid level determinations

IP EX Dietary education : Diet low purine
 UREMIA
ASSESMENT -
IP DX -
IP TX INTAKE
dialysis is generally initiated when :
- creatinine clearance 10 mL/min (creatinine level of 8-10
mg/dL) or less or,
- for diabetic, 15 mL/min (creatinine level of 6 mg/dL).
- Early referral to a nephrologist for evaluation (when
creatinine level is >3 mg/dL) is essential preparation for
dialysis or transplantation
IP MX management of uremia are indicated for associated metabolic
and electrolyte abnormalities
IP EX Diet low salt
 HYPERTENTION GRADE I
ASSESMENT Dislipidemia, DM, uricemia

IP DX Lipid profile, blood glucose, ureum

IP TX - Non medication : 1) Restriction of activity promotes
physical deconditioning, 2) Dietary sodium restriction
to 2-3 g/day is recommended
- Medication : 1) ACEIs, 2) ARBs
IP MX 1) Clinical manifestation 2) Vital sign
IP EX Dietary sodium restriction to 2-3 g/day is
recommended
 ATRIAL FIBRILATION
ASSESMENT Paroxisimal, Persistent and Permanent
(chronic)
IP DX Echocardiography, Thyroid Function, Holter
Monitoring
IP TX - Being synus rhythm (cardioconvertion)
- Pharmacology = Anti arythmia drugs (type
IA, IB, IC, II, III, IV),
- Beta blocker
IP MX 1) Clinical manifestation 2) ECG
IP EX 1) Bed Rest, 2) Diet Low Fat
 LATERAL ISCHEMIA
ASSESMENT Stable and unstable angina pectoris
IP DX 1) ECG 2) echocardiography
IP TX • Basically disease

IP MX 1) Clinical condition 2) ECG

IP EX A diet low in saturated fat and dietary cholesterol
 FOLLOW UP
6/7/2012 7/7/12 8/7/12 9/7/2012 10/7/2012 11/7/2012

complaint dyspnea (+) Abdomen Edema Abdominal Abdominal -

strain (+) (+) paint (+) paint (↓)

BP 140/100 120/90 100/70 100/70 100/70 110/80

HR 100 x/m 65 x/m 72 80 84 80

RR 32 x/m 20 x/m 24 24 24 22

t 36,7 36,2 36,3 36,6 36,3 36,8

THANK YOU