CASE BASED DISSCUSION

PATIENT IDENTITY
Name : Mrs. SR Age : 54 years old Gender : female Religion : Moslem Address : Banyumanik Semarang Room : Baitul Izzah 1 (411.1) Check in date : 15 MAY 2013 Check out date : 20 MAY 2013

HISTORY TAKING
Oedem

Patients had major complaints abdominal bloating. Said her stomach enlarges slowly on all parts of the abdomen since 1 month before entering the hospital. His stomach felt increasingly enlarged and increased tension, but this enlarged abdominal complaints not to make the patient tightness and difficulty breathing. The patient also complained of pain in the epigastrium since 1 month but damning since 3 days before entering the hospital. Pain in the epigastrium is like prickling and constantly felt by the patient throughout the day. The complaint does not say improved or worsened by food. Pain was also accompanied by complaints intermittent nausea that is felt but is felt throughout the day, and vomiting usually occurs after a meal. Vomit contains food or drinks are eaten previously, with a volume of approximately cup aqua, but no blood. Complaint nausea and vomiting is to make patients become reluctant to eat (no appetite). Patients also complain of fatigue since 2 weeks before entering the hospital. Perceived weak complaint said continuous and does not disappear even patient has rested. This complaint is said to be felt in all parts of the body and increasingly become heavy from day to day until 6 days before admission patients can not perform daily activities.

HISTORY TAKING
Oedem

In addition, patients also complain of swelling in both feet and hand since 1 month before entering the hospital which made walking difficult patients. Swelling said to be neither increased nor diminished when worn walking or rested. Complaints of leg swelling is not accompanied by pain and redness. Denied a history of trauma to the foot of the patient. The patient said that the defecate is normal, with frequency of 12 times per day. Micsi is like tea colour. Pain when urinating denied by the patient. History of skin yellowing of the patient's body denied. Finally, the patient feels restless and disturbed sleep at night. Complaints body heat, hair loss and bleeding gums denied by the patient.

HISTORY TAKING
History of previous illness
Hypertension (-) Liver disease (-) Kidney disease (-) Diabetes mellitus (-) Heart disease (-)

Family history of disease Fathers patient had died because of a heart disease Social economic history Status of patient is general. Patients Economic is average.

Systemic Anamnesis

PHYSICAL EXAMINATION
General

dyspneu (-) Compos mentis

Weight = 87kg; Height = 170 cm
BMI= BB(kg)/TB(m)= 87/(1,70)2 = 30,1 (obes)

Awareness
Nutrient state BMI

Vital Sign

TD 130/80 mmHg HR 84/menit RR 20 X/m T 36,5 C

Head Eyes Nose Ears Throat Mouth Neck Extremity

Mesocephal, alopesia (-) Anemic Conjuntival (-/-), Jaundice Sclera(-/-) Secret (-), Nostril Breath (-) Normal Shape, Discharge (-/-) Hyperemic (-), Pain Devour (-) Cyanosis (-), Dry Lips (-), Trachea Deviation (-), Lymph Hypertrophy (-) edema of upper and lower extremity (+)

Interpretation : prehypertension, edema of upper and lower extremity (+)

THORAX - PULMONARY
INSPEKSI Static ANTERIOR RR : 20 x/min, Hiperpigmentation (-), spider nevi (-), atrofi M. Pectoralis (-), 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 sonor Vesicular(+), ronchi (-), wheezing (-) POSTERIOR RR : 20 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 sonor Vesicular(+), ronchi (-), wheezing (-)

Dinamic

Palpation

Percution Auskultation

THORAX - COR
Inspection : Ictus cordis seen. Palpation : Ictus cordis is palpable in ICS VII linea mid clavicula sinistra, thrill (-). Percussion : dull sound Upper borderline of heart : ICS II linea sternalis sinistra Waist of heart : ICS III linea parasternalis sinistra Lower right borderline of heart : ICS VI linea parasternalis dextra Lower left borderline of heart : ICS VII 2 cm lateral linea mid clavicula sinistra Auscultation : Aorta Valve : SD I-II pure, regular, AI<A2 Trikuspid Valve : SD I-II pure, regular, T1>T2 Pulmonal Valve : SD I-II pure, regular, P1<P2 Mitral Valve : SD I-II pure, regular, M1>M2 Addition Sound : (S3 -) Interpretation : susp. cardiomegali

ABDOMEN
Inspection : distention(+), cycatric(-), striae(-), caput medusa (-). Auscultation : peristaltic (+) N Percution : shifting dullness (+), traube space (-) Palpation Superficial : massa (-) Deeper : abdominal pain (+), hepar & lien are difficult to evaluate, renal isnt palpable

Interpretation: susp. Ascites, splenomegali

Extremities

Extremities - edema - cold extremity - reflect physiologist - Icteric

superior +/+ -/+/+ -/-

inferior +/+ -/+/+ -/-

Laboratory Findings

LABORATORY
15-5-2013 Hemoglobin Hematokrit Leukosit Hematologi 10,04 g/dl L 30,5% L 13,06 3/uL H 603/Ul L 0,3% L 0,4 % 68,4 % 17,4 %L 13,5 % H 48 H 73 H Normal 11,7-15,5 mg/dl 33-45% 3,6-11rb/ul

Trombosit
Eosinofil % Basofil % Neutrofil % Limfosit % Monosit % LED 1 LED 2

150440rb/ul
1-3 0-1 50-70 25-40 2-8 0-20mm/jam 0-20mm/jam

Golongan darah/Rh O/+

15-5-2013 Ureum Creatinin SGOT

KIMIA 35 1,03 H 59 H

Normal 10-50mg/dl 0,5-0,9mg/dl UI

SGPT

39 H

UI

HbSAg kualitatif (-)

16-5-2013 warna Kejernihan Protein

Urin lengkap Kuning Agak keruh (-)

Normal

<30mg/dl

Reduksi
Bilirubin Reaksi/pH Urobilinogen Benda keton Nitrit Berat jenis Blood Leukosit

(-)
(-) 6,0 0,2 (-) (-) 1005L 80 H 70 H

<15mg/dl
<1mg/dl 4,8-7,4 <2mg/dl <15mg/dl (-) 1015-1025 <5eri/ul <10leu/ul

16-5-2013 Mikroskopis Epitel sel Eritrosit Leukosit Silinder Parasit Bakteri Jamur Kristal Benang mukus

Urin lengkap

Normal

3-4 10-12H 15-20H (-) (-) (-) (-) (-) (-)

5-15/LPK 0-1/LPB 3-5/LPB 0-1(Hialin)/LPK (-) (-) (-)

16-5-2013 GD2PP GDP Cholesterol

Kimia 207 mg/dlH 114H 82

NORMAL < 120mg/dl 74-106mg/dl <200mg/dl

17-5-2013 Total protein Globulin Albumin

Kimia 7,32 4,83 2,49 L

Trigliserid
HDL LDL Asam urat Total protein Globulin Albumin

64
22 L 37 L 3,7 6,98 4,90 2,08 L

<160mg/dl
37-92mg/dl 60-130mg/dl 2,6-5,7mg/dl 6,0-8,0 g/dl

Date
15.5.2012 16.5.2012 18.5.2012

GDS
201mg/dl 205mg/dl 118mg/dl

3,4-4,8 g/dl

EKG

INTERPRETATION
1. Rhythm 2. Heart Rate 3. Axis 4. Zona Transisi 5. Morphology : - P wave - Interval PR - QRS complex - ST segment - T wave - Interpretation : Iregular :: Lead I (+) ; AVF (+) Normo Axis Deviation : V3 : Normal (0.12 sec) : Normal (0,12 - 0,16 sec) : VES (>0.12 sec) : isoelektris : Inverted (-) T tall (-) : VES benigna (aVR)

RADIOLOGY

Susp.Cardio megali

Interpretation
Thorax X-ray examination CTR can not be assessed, apex shifted to laterokaudal (suspected cardiomegaly) Pulmo: image of vascular normal, no visible spots on both lungs Right diaphragm as high as 8 posterior costa, both costophrenic sinus

USG ABDOMEN

Interpretation
Overview of the process of chronic liver with mild splenomegaly liver cirrhosis suspicious Yet signs of portal hypertension Kidney and pancreas within normal limits Ascites

Abnormalitas Data
Anamnesis 1. Abdominal bloating 2. Pain in the epigastrium 3. Nausea 4. Vomit 5. Micsi like tea 6. Fatigue 7. Oedem extremity
Physic Examination : 8. obesity 9. Prehipertension 10. edema of upper and lower extremity 11. susp. Cardiomegali 12. Distention(+) 13. Shifting dullness (+) 14. Traube space (-) 15.Abdominal pain (+)
Advance Examination: 16. Anemia 17. Leukositosis 18. Trombositopenia 19. Eosinofil (L) 20. Limfosit (L) 21. Monosit (H) 22. LED 1/2 (H) 23. Creatinin (H) 24. SGOT & SGPT (H) 25. Urin : berat jenis (L) 26. Hematuria 27. Leukosit urine (H) 28. Hiperglikemia 29. Hipoalbuminemia 30.VES 31. Ro thorax : susp kardiomegali 32. USG Abdomen : splenomegali, susp sirosis hepatic, ascites

PROBLEM LIST

Asites Sirosis hepatis CHF Hiperglikemia Hipoalbuminemia

Asites
Abdominal bloating Distention(+) Shifting dullness (+) Leukositosis Hipoalbuminemia

USG Abdomen : ascites

Sirosis hepatis

Pain in the epigastrium Nausea Vomit Micsi like tea Fatigue Traube space (-) Abdominal pain (+) Anemia

Trombositopenia LED 1/2 (H) SGOT & SGPT (H) Hipoalbuminemia USG Abdomen : splenomegali, susp sirosis hepatic, asites

CHF

Abdominal bloating Fatigue Oedem extremity edema of upper and lower extremity susp. Cardiomegali Distention(+) Shifting dullness (+) Ro thorax : susp kardiomegali

Hiperglikemia

GDS (H) GD2PP (H) GDP (H)

Hipoalbuminemia

Albumin (L)

Ass

IP Mx

IP Dx

IP Mx

IP Tx

Ass transudat, eksudat Ip Dx : px. SAAG ( Serum Acites Albumin Gradient) Non Farmakology : Diet enough salt 2 gram/ day Diit low liquid 1 liter/ day

: inj Furosemid 3 X 10 mg/ml spironolacton 3 X 100mg tab Ip Mx : Darah rutin , chemistry blood ( ureum, creatinin, albumin, globulin, totalprotein), Ip Ex : bed rest, reduce dringking and salt

Farmakology

Ass : Kompensata, Dekompensata IP Dx : Biopsi hati Ip Tx : Non Farmacology Bed rest Farmacology inj cefotaxime 2 x1 Curcuma 2 x 1 Ip Mx : SGPT, SGOT, albumin, routine blood, HBsAg Ip Ex : eating from hospital, bed rest

Assessment (LVH,LAH)

: Anatomi diagnosis

Farmacology O2 2-3 L/minutes

Etiologi diagnosis (HHD,IHD), Cardiomiopaty, LV Fraksi ejection

Dislipidemia

Digoxin (2x1/2tab) Spironolakton 1x 25 mg Inj Furosemid 3 x 1 amp ISDN 3x 5 mg

IP. Dx : Echocardiography

LVEF

IP. Mx : Vital Sign, Fluid Balanced, Electrolit lab, Electrocardiography IP. Ex : Eat and drink as ruled of hospital Use canul O2 if the patient feel short breathness No drink alcohol, coffee, no cigarrete Mild Exercise 30 minutes everyday use drug as treatment reguarly

IP. Rx :

Non Farmacology :

diet low salt and low protein

Bed Rest of sit down position Drink water < 1,5-2 l/day (especially in patient hyponatremia) Diet High Kalori low Protein low salt )

Assessment :DM type I, DM type II, Another DM IP. Dx : HbA1c IP. RX

Non Farmacology

Diet low glucose Increase Physical exercise Educating about Diabetes Mellitus

Farmacology : OHO, Insulin Injection

IP. Mx : General Condition, GDS, GDP, GD2PP IP. EX :

Needed controlling and examination for DM Diminished intake high carbohydrate and fatty Do the mild exercise and moderate regulary

Ass: albuminuria IP Dx : IP Tx : transfusi albumin perhitungan albumin = (3,5 Kadar albumin) x 0,8xBB = (3,5 -2,08)x 0,8 x 87kg = 98,8 4 albumin x25 % 100 cc Sediaan dipasaran 20 % 100 cc, 25 % 100 cc, 20 % 50 cc, 25 % 50 cc 25 % 50 cc IPMonitoring : replay albumin test everyday

Follow Up
Date BP HR RR T GDS S
Oedem of Upper and lower extremities, abdominal bloating, nausea, vomit, pain in epigastrium, fatigue

P
ECG,RO Thorax, USG Abdomen, salt , Diet low glucose

15.5.2 013

130 80

84x

36,5 20x oC

201

prehypertension, ascites, hiperglikemi

16.5.2 013

130 80

84x

24x

36 oC

205

Oedem of Upper and lower extremities, abdominal bloating, fatigue

Oedem of Upper and lower extremities, abdominal bloating, fatigue, headache

prehypertension, ascites, hiperglikemi

salt , Diet low glucose .

17.5.2 013

150 80

92x

36,4 20x oC

Hypertension grade I, ascites

salt , Diet low glucose .

Follow Up
Date BP HR RR T GDS S
Oedem of Upper and lower extremities, abdominal bloating, fatigue, headache

18.5.2 013

140 90

62x

20 x

36,5 oC

118

Hypertensio n grade I, ascites, hiperglikemi

salt , Diet low glucose .

19.5.2 013

130 80

78x

22 x

36,5 oC

Decrease Oedem of Upper and lower extremities, decrease abdominal bloating, fatigue

prehyperten sion, ascites

salt , Diet low glucose .

20.5.2 013

130 80

76x

18 x

36,5 oC

fatigue

prehyperten sion

salt , Diet low glucose .

BB : 87 kg TB : 170 cm Aktivitas : istirahat BBI = (TB-100) x 1kg = (170 -100) x 1kg = 70 kg Status Gizi = (BB : BBI) x 100% = (87 : 70 ) x 100% = 124%

HITUNG KALORI

Calori Basal = BBI x 25 Calori/kg = 70 x 25 Calori /kg = 1750 Calori/kg Koreksi Umur 40 59 year (-5%) = - 87,5 calori Aktivitas istirahat (+10%) = + 175 calori Obesity (-20%) = - 350 calori Total = 1487,5 kalori 1450 calori

Terima Kasih Wassalaamu'alaykum Wr.Wb.