CBD

CASE BASE DISCUSSION

MOHAMAD REZA HENDRATMOKO
30101206681
Advisor : dr. H. M. SAUGI ABDUH, Sp.PD., KKV, FINASIM

Department of Internal Medicine

Medical School of Sultan Agung Islamic University
2016

PATIENTS IDENTITY
Name
Age

: Mrs. S
: 56 y.o.

Gender

: Female

Religion

: Moslem

Job

: Seller

Address
: Banjardowo RT 9/4 Genuk
Semarang
MR number
Room

: Baitul Izzah 1 411.2

Entry date
Date out

: 01-26-47-51
: August 11th, 2016
: August 15th, 2016

HISTORY TAKING
Main
Proble
m

Chest
Pain
Patient

came

into

the

emergency

department in Islamic Hospital of Sultan

History
of
Present
Illness

Agung Semarang, complained about her

chest pain. Its started at 8 August 2016. The
pain localized on substernal and radiate to
her back. At that day, the pain often come
and worsening when do an activity. Duration
of the pain + 30 minutes. She felt better
when she took a rest. She also complained
epigastrial pain, nausea and vomitus.

HISTORY OF ILLNESS
HISTORY OF PREVIOUS ILLNESS
Hypertension history (+)
DM history

(-)
(-)

Alergy history

(+)

SMOKING (-)
FAMILYS HISTORY OF DISEASE
Hypertension history (+)

Asthma history

HISTORY :
Hospital cost certified

Asthma history

DM history

SOSIO-ECONOMIC

(-)
(-)

by
SELF PAYMENT

SISTEMIC
ANAMNESIS
Chief Complains

: Chest pain

Onset

: 1 days ago

Location

: Substernal

Chronology

: Patient felt this pain after sell at store

Quality and Quantity : The pain worsening when do activity.

The pain spread to her back. The pain attack come more
than one time, each attack worsening and longer
Modification factor

: Better when she took a rest

Comorbid complains : Epigastric pain, nausea, vomitus

General
Skin

PHYSICAL
EXAMINATION
: composmentis

:itching(-),jaundice(-),pale(-)
Head

:headache(-)

Eyes

:blurredvision(-),red

eyes(-),
Ears

ictericsclera(-/-)
:hearingloss(-),ring(-),
discharge(-)

Nose

:nosebleed(-),discharge(-)

Mouth

:cyanosis(-), thrush(-),
bleeding gums(-)

Throat

:painswallow(-), hoarseness(-),
odinifagia(-)

Neck

: enlargement ofthe gland(-)

Chest

:cough(-),sputum(-),blood(-)

Cardiac

:chest pain(+),palpitations(-)

Digestive :abdominal pain (+),nausea(+),

vomiting(+)
Musculoskeletal :weak(-),rigid(-),back pain (-)
Extremity : oedem extremity (-)

GENERAL STATUS
BMI (Body Mass Indeks)
BMI (Body Mass Indeks)
weight : 67
BMI= (1,67 x 1,67) : 67 = 24,0
weight : 67
BMI= (1,67 x 1,67) : 67 = 24,0
High : 160
High : 160
Intepretation

:
Intepretation :
Normoweight
Normoweight

General : Chest pain

General : Chest pain
Awareness : Fully Aware / Compos Mentis (GCS=15)
Awareness : Fully Aware / Compos Mentis (GCS=15)

Vital Sign
Vital Sign
Blood Pressure : 230/130 mmHg
Blood Pressure : 230/130 mmHg
Heart rate : 80 x/minute
Heart rate : 80 x/minute
Breath Frequency : 24 x/minute
Breath Frequency : 24 x/minute
Temp
: 36,0oC
Temp : 36,0oC

Intepretation : Crisis
Intepretation : Crisis
Hypertension
Hypertension

GENERAL STATUS
Head : Mesocephal, alopesia (-)
Head : Mesocephal, alopesia (-)
Eyes : Anemic Conjuntiva(-/-),Icteric sclera(-/-)
Eyes : Anemic Conjuntiva(-/-),Icteric sclera(-/-)
Nose : symmetric, secret (-), Nostril Breath (-)
Nose : symmetric, secret (-), Nostril Breath (-)
Ears : Normal Shape, discharge (-/-)
Ears : Normal Shape, discharge (-/-)
Esophagus : Hyperemic (-), pain devour (-)
Esophagus : Hyperemic (-), pain devour (-)
Mouth
: Cyanosis (-), dry lips (-),
Mouth
: Cyanosis (-), dry lips (-),
Neck : Trakhea deviation (-), Lymph Hypertropy (-)
Neck : Trakhea deviation (-), Lymph Hypertropy (-)
Extremity
: Oedem of lower extremity / upper extremity
Extremity
: Oedem of lower extremity / upper extremity
(-) / (-)
(-) / (-)

Intepretation : Normal
Intepretation : Normal

LUNG
EXAMINATION
INSPEKSI

ANTERIOR

POSTERIOR

Static

RR : 24x/min, Hyper pigment (-), spider

RR : 24x/min, Hyper pigment

nevi

(-),spider nevi (-), Hemithoraks

(-), atrophy Pectoral Muscle (-),

D=S,

Hemithoraks D=S, ICS Normal, Diameter

ICS Normal, Diameter AP < LL

AP < LL
Dynamic

Up and down of hemitoraks D=S,

Up and down of hemitoraks D=S,

abdominothorakal breathing, (-), muscle

abdominothorakal breathing (-),

retraction of breathing (-),

muscle retraction of breathing(-),

retraction ICS (-)

retraction ICS (-)

Palpable pain(-), tumor (-), Arcus costae

Palpable pain (-), tumor (-), Arcus

angle < 900, enlargement of ICS (-), Stem

costae angle < 900, enlargement of

fremitus D=S

ICS (-), Stem fremitus D=S

Percution

Sonor

Sonor

Auskultati

Vesicular (+), Whezzing (-), Ronchi (-)

Vesicular (+), Whezzing (-),

Palpation

on

Ronchi (-)

Intepretation :
Intepretation :
NORMAL
NORMAL

CARDIAC
EXAMINATION

Inspection : Ictus cordis isnt seen.

Inspection : Ictus cordis isnt seen.

Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-),

Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-),
sternal lift (-).
sternal lift (-).
Percussion : dull sound
Percussion : dull sound
Upper borderline of heart : ICS II left sternal line
Upper borderline of heart : ICS II left sternal line
Waist of heart : ICS III left parastern line
Waist of heart : ICS III left parastern line
Lower right borderline of heart : ICS V right sternal line
Lower right borderline of heart : ICS V right sternal line
Lower left borderline of heart
: ICS V, 2 cm lateral from left mid
Lower left borderline of heart
: ICS V, 2 cm lateral from left mid
clavicle line
clavicle line

CARDIAC...CONT
Auscultation
Auscultation
Aortal valve : S1 & S2 standard, additional sound (-)
Aortal valve : S1 & S2 standard, additional sound (-)
Pulmonary valve: S1 & S2 standard, additional sound (-)
Pulmonary valve: S1 & S2 standard, additional sound (-)
Tricuspid valve : S1 & S2 standard, additional sound (-)
Tricuspid valve : S1 & S2 standard, additional sound (-)
Mitral valve : S1 & S2 standard, additional sound (-)
Mitral valve : S1 & S2 standard, additional sound (-)

Intepretation : NORMAL
Intepretation : NORMAL

ABDOMEN
EXAMINATION

Inspection
: symetric, sycatric(-), striae(-),enlargement of vena (-),
Inspection
: symetric, sycatric(-), striae(-),enlargement of vena (-),
caputmedusa (-).
caputmedusa (-).
Auscultation : peristaltic (+)
Auscultation : peristaltic (+)
Palpation :
Palpation :

Superfisial : tight (-), mass (-), epigastrial pain (+)

Superfisial : tight (-), mass (-), epigastrial pain (+)

Deep : abdominal pain (-), liver, kidney, and spleen werent

Deep : abdominal pain (-), liver, kidney, and spleen werent

palpable, Murphys sign (-)
palpable, Murphys sign (-)
Percussion
: tympani, side of deaf (-), shifting dullness (-)
Percussion
: tympani, side of deaf (-), shifting dullness (-)

Liver
: deaf(+), right liver span 11 cm, left liver span 6 cm

Liver
: deaf(+), right liver span 11 cm, left liver span 6 cm

Spleen
: Throbe space percussion (+) tympani

Spleen
: Throbe space percussion (+) tympani

Intepretation: :
Intepretation
abdominal
pain
abdominal pain

EXTREMITY
EXAMINATION

EkstremitasSuperior Inferior
EkstremitasSuperior Inferior

Oedema
-/-/Oedema
-/-/
Cold
-/-/Cold
-/-/
Jaundice
-/-/Jaundice
-/-/-

LAB. EXAMINATION
Examination

Result

Examination

Result

Cholesterol

203 mg/dl

Hemoglobin

12,9 g/dl

Trigliserid

71 mg/dl

Hematokrit

38,2 %

HDL

46 mg/dl

Leukosit

18,04 ribu/ uL

LDL

132 mg/dl

Trombosit

332 ribu/ uL

Uric acid

5,4 mg/dl

0,11 ug/L

Ureum

18 mg/dl

Troponin I
Ultra

Creatinin

0,58 mg/dl

Intepretation :
Intepretation :
Hipercolesterol
Hipercolesterol
LDL
LDL
Leukositosis
Leukositosis
Elevation of cardiac marker
Elevation of cardiac marker

SERIAL ECG

11/8/16

ECG 11/8/2016
IRAMA : Sinus rhytm
IRAMA : Sinus rhytm
REGULARITAS : Regular
REGULARITAS : Regular
FREKUENSI : 93x/menit
FREKUENSI : 93x/menit
AXIS : L1 (+) AVF (-) -> LAD
AXIS : L1 (+) AVF (-) -> LAD
GELOMBANG P : 2 x 0,04 = 0,08 s
GELOMBANG P : 2 x 0,04 = 0,08 s
PR INTERVAL
: 4 x 0,04 = 0,16 s
PR INTERVAL
: 4 x 0,04 = 0,16 s
QRS COMPLEX : 0,08 s
QRS COMPLEX : 0,08 s
ST SEGMEN
: ST depression (L II, aVF, V4, V5)
ST SEGMEN
: ST depression (L II, aVF, V4, V5)
GELOMBANG T : T prekordial : <10 mV T ekstremitas : <5 mV
GELOMBANG T : T prekordial : <10 mV T ekstremitas : <5 mV
t inverted (V1)
t inverted (V1)
ZONA TRANSISI : V4
Intepretation :
ZONA TRANSISI : V4
Intepretation :

1. LAD
1. LAD
2. Ischemic on inferior and
2. Ischemic on inferior and
anterior

12/8/16

ECG 12/8/2016
IRAMA : Sinus rhytm
IRAMA : Sinus rhytm
REGULARITAS : Regular
REGULARITAS : Regular
FREKUENSI : 93x/menit
FREKUENSI : 93x/menit
AXIS : L1 (+) AVF (-) -> LAD
AXIS : L1 (+) AVF (-) -> LAD
GELOMBANG P : 2 x 0,04 = 0,08 s
GELOMBANG P : 2 x 0,04 = 0,08 s
PR INTERVAL
: 4 x 0,04 = 0,16 s
PR INTERVAL
: 4 x 0,04 = 0,16 s
QRS COMPLEX : 0,08 s
QRS COMPLEX : 0,08 s
ST SEGMEN
: ST depression (L II, aVF)
ST SEGMEN
: ST depression (L II, aVF)
GELOMBANG T : T prekordial : <10 mV T ekstremitas : <5 mV
GELOMBANG T : T prekordial : <10 mV T ekstremitas : <5 mV
T inverted (V1, V3)
T inverted (V1, V3)
Intepretation :
ZONA TRANSISI : V4
Intepretation
:
ZONA TRANSISI : V4

1. LAD
1. LAD
2. Ischemic on inferior and
2. Ischemic on inferior and
anterior
anterior

13/8/16

ECG 13/8/2016
IRAMA : Sinus rhytm
IRAMA : Sinus rhytm
REGULARITAS : Regular
REGULARITAS : Regular
FREKUENSI : 93x/menit
FREKUENSI : 93x/menit
AXIS : L1 (+) AVF (-) -> LAD
AXIS : L1 (+) AVF (-) -> LAD
GELOMBANG P : 2 x 0,04 = 0,08 s
GELOMBANG P : 2 x 0,04 = 0,08 s
PR INTERVAL
: 4 x 0,04 = 0,16 s
PR INTERVAL
: 4 x 0,04 = 0,16 s
QRS COMPLEX : 0,08 s
QRS COMPLEX : 0,08 s
ST SEGMEN
: ST depression (L II, aVF)
ST SEGMEN
: ST depression (L II, aVF)
GELOMBANG T : T prekordial : <10 mV T ekstremitas : <5 mV
GELOMBANG T : T prekordial : <10 mV T ekstremitas : <5 mV
T inverted (V1, V3)
T inverted (V1, V3)
Intepretation :
ZONA TRANSISI : V4
Intepretation
:
ZONA TRANSISI : V4

1. LAD
1. LAD
2. Ischemic on inferior and
2. Ischemic on inferior and
anterior
anterior

14/8/16

ECG 14/8/2016
IRAMA
: Sinus rhytm
IRAMA
: Sinus rhytm
REGULARITAS
: Regular
REGULARITAS
: Regular
FREKUENSI
: 93x/menit
FREKUENSI
: 93x/menit
AXIS
: LAD
AXIS
: LAD
GELOMBANG P : 2 x 0,04 = 0,08 s
GELOMBANG P : 2 x 0,04 = 0,08 s
PR INTERVAL
: 4 x 0,04 = 0,16 s
PR INTERVAL
: 4 x 0,04 = 0,16 s
QRS COMPLEX : 0,08 s
QRS COMPLEX : 0,08 s
ST SEGMEN
: isoelektris
ST SEGMEN
: isoelektris
GELOMBANG T : T prekordial : <10 mV T ekstremitas : <5 mV
GELOMBANG T : T prekordial : <10 mV T ekstremitas : <5 mV
ZONA TRANSISI : V3
ZONA TRANSISI : V3

Intepretation : NORMAL
Intepretation : NORMAL

ECG SERIAL RESULT

ECG RESULT
DATE

ST
depressio
n

T
inverte
d

Enlarge
ment

INTERPRETATION

11/8/2016

L II, aVF,
V4, V5

V1, V2

LI (+),
AVF (-)

SNR, LAD, Ischemic on

Inferior+anterior

12/8/2016

L II, aVF

V1, V3

LI (+),
AVF (-)

SNR, LAD, Ischemic on

Inferior+anterior

13/8/2016

LII, aVF

V1, V3

LI (+),
AVF (-)

SNR, LAD, Ischemic on

inferior, non spesific
anterior

14/8/2016

isoelektris

LI (+),
AVF (+)

SNR, NAD

Axis

Abnormal Data

ECG :
7. LAD
8. ST depression

Physical
History Taking
1. Chest pain,
2.Stomach pain, 3.
Nausea, 4.Vomitus

Examination
5. Epigastrial
pain
6.High blood
pressure :
230/130

9. T inverted
Lab
Hematology
10. Total kolesterol
11. LDL
12. Leukositosis
13. Elevation of
Cardiac marker

PROBLEMLIST
LIST
PROBLEM
1
SKA
SKA
(1, 8, 9, 13)
(1, 8, 9, 13)

DISLIPIDEMI
DISLIPIDEMI
A
A
(10, 11)
(10, 11)

2
CRISIS
CRISIS
HYPERTENSION
HYPERTENSION
(6)
(6)

DISPEPSIA
DISPEPSIA
(2, 3, 4, 5)
(2, 3, 4, 5)

1.
ska

Ass: UAP
NSTEMI

Pharmacology
O2 nasal canul 4L/minute

IP Dx : Angiografi koroner

Bisoprolol 2,5 mg

1x1

IP Tx :

ISDN subl. 5 mg

3x1 prn

Aspillet 80 mg

1x1

Non Pharmacology

Low cholesterol intake

CPG 75 mg

1x1

Reduce activity

truvast (atorvastatin)

High fiber diet

Heparin

0-0-1

Ip. Mx : Vital sign, ECG serial, echocardiography, APTT

Ip. EX :

Bed Rest/Restriction of physical activity

Reduce fatty food

Control blood pressure

Reducing Emotional stress

Routine consumption drugs

Consumption of antioksidan (green tea)

Avoid smoking

Do sport regularly, 4 times each week, duration: 30-60

minutes

1. SKOR TIMI
Parameter

Skor

Hasil

Usia >65 th

Lebih dari 3 FR

Angiografi stenosis
>50%

Penggunaan aspirin 7
hari terakhir

2 Episode/ lebih nyeri

dada saat istirahat

Deviasi T >1mm saat

tiba

Elevasi cardiac
marker

TOTAL

INTERPRETASI

MENENGAH

2. SKOR GRACE
PARAMETER

SKOR

Usia

36

HR

Sistol

Kreatinin

KILLIP

Cardiac arrest

Peningkatan cardiac marker

15

Deviasi segmen ST

30

TOTAL

93

INTERPRETASI

RESIKO RENDAH (<1%)

4. SKOR CRUSADE
DM

SKOR

Hematokrit awal

Klirens kreatinin

HR

Jenis kelamin

Tanda gagal jantung

saat datang

Riwayat penyakit
vaskuler sebelumnya

DM

Tekana dararh sistol

TOTAL

23

INTERPRETASI

RENDAH (5,5%)

HAS BLED SCORE

PARAMETER
Hypertension history

SKOR
+1

Renal disease

Liver disease

Stroke history

Prior major bleeding or

predisposition to bleeding

Labile INR

Age >65

Medication usage predisposing to

bleeding

Alcohol or drug history

TOTAL

+1

INTERPRETATION

LOW RISK

Framingham score to assess risk

to become IHD
PARAMETER

SCORE

Usia

Kolesterol total

Perokok/bukan

HDL

Tekanan darah

TOTAL SCORE

17

% FAKTOR RESIKO dalam 10

tahun menjadi PJK

5%

INTERPRETASI

MODERAT

Skala resiko Framingham

Resiko tinggi : pasien dengan PJK , score > 20%

Resiko tinggi moderat : mempunyai 2 FR selain LDL, score 10% 20%

Resiko moderat : mempunyai 2 faktor resiko selain LDL, score <

10%

Resiko rendah : mempunyai 0-1 faktor resiko selain LDL

Stratifikasi resiko

Rendah : pasien tidak memiliki kelainan angina sebelumnya dan

sudah tidak ada serangan angina, tidak memakai obat anti
angina dan ECG normal, enzim jantung tidak meningkat,
biasanya masih muda

Sedang : angina baru, makin berat, angina waktu istirahat, tidak

ada perub segmen ST, enzim jantung tidak meningkat

Tinggi : angina istirahat, angina berlangsung lama atau post

infark, sebelumnya sudah mendapat terapi yang intensif, usia
lanjut, perubahan segmen ST, kenaikan enzim jantung,
hemodinamik tidak stabil

2.
CRISIS
HYPERTENSION

Ass : Emergency hypertension

Urgency hypertension

Ip Dx : Funduscopi, X foto thorax, USG abdomen, brain ct scan,

arteriografi, echocardiography, protein urine

Ip Tx :
Non Pharmacology :
Bed rest
Low salt intake
Low fat and high fiber diet
Pharmacology : inj. Diltiazem 0,2 mg/kgBB

Ip. Mx : Blood pressure, neurological status (GCS), cardiopulmonary

status, body fluid volume assesment

Ip.Ex :
Diet low salt
Consumption vegetable, fruit
Routine consumption drugs

3.
DISLIPIDEMIA
Ass: IP Dx : IP Tx :
Pharmacology :
Atorvastatin

20 mg 0-0-1

RESUVASTATATIN
Non pharmacology
Daily dietary consumption of fruits and vegetables
Exercise 60 minutes with aerobic and resistance
training
Achieve ideal body mass index and body weight

Ip.Mx : total cholesterol, HDL, LDL, trigliserid

Ip.Ex :
Eat high fiber diet and low fat
Reduce fatty food, soda and junk food
Low exercise regularly

Dislipidemia Score
(ESC)

Age : 56

Women

Non smoker

Sistol : 180

Kolesterol total : 203

SCORE = 3

Risk : Moderate risk to CVD

Therapy of dislipidemia
(AHA)

Statin Therapy

4.
DISPEPSI
Ass: Functional dispepsia (Post prandial
A
distress syndrome, epigastric pain syndrome)
Organic dispepsia (duodenal ulcer, gastric
ulcer, gastritis)

test, PPI Test

IP Tx :
Pharmacology

Ondansetron
Sukralfat syr

Reduce fiber food, spicy

and acid food
Avoid alcohol, soda

IP Dx : Kontras OMD, endoskopi, urea breath

Omeprazole 20 mg

Non pharmacology

2x1
3x4mg
3x1 C

Reduce emotional stress

 Ip.Mx : Dehidration state, general examination (ikterik,

odinofagia, vomitus, nausea, limfadenopathy,
hematemesis/melena without etiology), Hb
Ip.Ex :
Reduce eat spicy, acid and fatty food
Avoid alcohol, soda
Reduce emotional stress
Increase diet frequent with small portion

Alarm symptom for

dispepsia

1.

Decreasing of weight gain > 10% without any reason

2.

Progressive disfagia

3.

Vomitus frequent

4.

Gastrointestinal bleeding

5.

Anemia

6.

Fever

7.

Epigastrium mass

8.

Family history of ca gaster

9.

Acute dispepsia on age 45