CASE BASED

DISCUSSION
Nadya Reza Nanda B
30101407259

Advisor :
dr. H. M. Saugi Abduh , Sp.PD, KKV, FINASIM
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• Name : Mrs. E
• Medical Record : 01-37-51-64
• Age : 49 years old
• Gender : Female
• Religion : Moslem
• Job : Housewife
• Address : Dukuh Bangker 3/3 Rembang
• Room : Baitul Izzah 2
• Patient came on : Friday, 15 th of March 2019
• Data : Monday, 18 th of March 2019
• Main Complaint : Dyspnea
• Patient came to emergency room in Sultan Agung Islamic
Hospital complained dyspneu. The dyspneu as if being
suppressed that she felt worsen on hard activity and got better
when take a rest sice 4 days ago. she complained dyspneu
when resting or sleeping position but it will become better with
sitting position (Orthopneu) so that the patient can’t sleep.
• she also complaint chestpain in her left chest, tingling
senstion and numbness in her leg and hand
her chestpain was felt for about 30 minutes in each time,
and it felt like “someone was squeezed her chest”, with
burning sensation, and localized. Her complaints will be
heavier when she did her job and walk for about 50
meters. She decide to take a pill from emergency
installation to reduce her problem,
• She does a routine medical examination in RSUD
Rembang for about 5 months, on Thursday, she felt her
chestpain when she took a rest , then she came to
Regional Public Hospital’s emergency installation in
Rembang but her complaints wasn’t going better,
patient was referrred to Sultan Agung Islamic Hospital
at Friday .
• History of Same Illness
• Hypertension History
• DM History
• Kidney Disease History
• History of Drug Allergy
: (+) (since 10 years ago)
: (+) (since 10 years ago)
: (+) (since 5 years ago)
: (-)
: (-)
• History of Same Illness : (-)
• Hypertension History : (-)
• DM History : (-)
• Heart Disease History : (-)
• Kidney Disease History : (-)
• History of Drug Allergy : (-)
• The medication fee guaranteed by “BPJS” class 2
 SYSTEMATIC ANAMNESIS
CHIEF dyspneu
-
COMPLAINT

4 days ago
ONSET

LOCATION chest

CHRONOLOGY suddenly
 SYSTEMATIC ANAMNESIS (Cont’d)

QUALITY worsen
- on sleep position and activity, got better when sit
position (Orthopneu)

QUANTITY Accidentally

MODIFYING Activity
FACTORS

OTHER Chestpain
COMPLAIN
 Patient Status

• Age : 49 years old

• Sex : Female

Nutrient Status Vital Sign

• Weight : 69 kg • BP : 130/80 mmHg

• HR : 80 x/m
• Height : 150 cm • RR : 20 x/m
• BMI : 30,67 •T : 36,8 oC

Grade 1 obese, pre

hypertension
• Head : normoocephal
• Eyes : Conjunctiva anemic (-/-), jaundice sklera (-/-)
• Nose : Nostril breath (-), discharge (-)
• Ears : Discharge (-),
• Throat : Hyperemia (-)
• Mouth : Cyanosis (-), Dry Lips (-)
• Neck : Lympadenopati (-), Increasing JVP (-)

Interpretation : normal
 Thorax - Cor
Inspection : Ictus cordis can’t be seen.

Palpation : ictus cordis is palpable at ICS VI, from linea axillaris anterior to
medial thrill (-), epigastric pulse (-), parasternal pulse (-),sternal lift (-).

Percussion : redup
 Upper borderline of heart : ICS II left sternal line
 Waist of heart : ICS III left parastern line
 Lower right borderline of heart : ICS V right sternal line
 Lower left borderline of heart : ICS VI, 2 cm lateral from left mid clavicle
line

Intepretation : Cardiomegaly
• 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

 INSPEKSI ANTERIOR POSTERIOR

Static RR : 20x/min, Hyper pigment (-), spider nevi RR : 20x/min, Hyper pigment
(-), atrophy Pectoral Muscle (-), Hemithoraks D=S, ICS (-),spider nevi (-), Hemithoraks D=S,
Normal, Diameter AP < LL ICS Normal, Diameter AP < LL

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

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

Faint (-)
Percution Faint (-)

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

Intepretation :
Normal
• Inspection:
• Symetric, sycatric(-), striae(-), scuama(-)
enlargement of vein (-), hyperpigmentation (-),
spider nevi (-)

• Auscultation :
• Normal Peristaltic (10 x/ minutes)

Interpretation : normal
 Percussion Palpation
Side of deaf (-), shifting Superfisial :
dullness (-), undulation test (-) • Mass (-)
• Abdominal pain (-)
Hepar : deaf (+), liver span
dextra 10 cm, liver span Deeper :
sinistra 7 cm Abdominal pain (-)
Hepar is not palpable, lien is
Lien : troube space  tympani not palpable, kidney is not
palpable.
 Superior Inferior
Oedem -/- -/-

Pitting Oedema -/- -/-

Cyanotic -/- -/-

Cold Extremity +/+ +/+

Capillary Refille <2s <2s

Clubbing Finger -/- -/-

Interpretation : normal
 Laboratory Examination Results Normal Value
Hemoglobin 13,8 g/dL 11,7 - 15,5 g/dL
Hematocrit 41,4% 33 – 45%
Leucocyte 7.100/dL 3.600 – 11.000/dL
Trombocyte 310.000/dL 150.000 – 440.000/dL
Blood sugar level 273

Interpretation :
hiperglikemi
cholesterol 304 <200 mg/dl
trigliserid 192 <160
SGPT 28 U/I 0 – 35 U/I
Direct HDL cholesterol 55 34-87 mg/dl
Direct LDL cholesterol 108 60-130 mg/dl
Ureum 27 10-50 mg/dl
Blood Creatinin 0.85 0.6-1.1 mg/dl
TNHS (High Sensitiv Troponin) 4.1 <0,01 ng/L
Na 141.6 mmol/L 135 – 147 mmol/L
K 3.69 mmol/L 3,5 – 5 mmol/L
Cl 101 mmol/L 95 – 105 mmol/L

Interpretation : dyslipidemia,
TNHS,
• Rhytm : sinus
• Regularitas : reguler
• Frekuensi : 79 x/menit
• Axis : lead 1 = +; AvF = +  NAD
• Zona Transisi : V3
• Gelombang P : tinggi 0,2mv lebar 0,12ms
• Interval PR : 0,16ms
• Komplek QRS : v5-v6 0,08 detik (normal)
• Gelombang Q : normal
• Segmen ST : normal
• Gelombang T : T inverted pada V1,V2,V3,V4

Kesan :Sinus takikardi with anterior ischemic

 Cor : the apex is move to
laterocaudal
Elongation in arcus aorta
Pulmo : normal
There are no abnormalities in
the diaphragm and
costophrenic sinus

Interpretation :
Suspect cardiomegaly
Elongation of arcus aorta
No infiltrate was found at the
pulmo
Echocardiography
 Anamnesis : Physical Pemeriksaan
Penunjang:
Examination: EKG :
8. LVH, Sinus
tachycardi with
1. Dyspneu d effort ischemic lateral
6. Cardiomegaly
5. Hipertensi
2. Ortopnoe Laboratory :
7. BMI 30.67
Kardiomegali
9. High blood sugar
3. Limp 6. Oedem ekstremitas level
10. High TNHS
4. Chest pain 11.
Hypercholesterolemi
5. Tingling and 12.
numbness in Hypertriglyceridemia

hand and foot

 13.
Echocardiography :
14. Foto Thoraks:
- Hypertrophy in left
- Cardiomegali
ventricle
- Aortic elongation
 2
1
CHF NYHA IV Acute coronary
1,2, 6,8,13,14
syndrome
3,4,10

3 4

Type II Diabetes Hyperlipidemi

mellitus 7,11,12
5,9
 CHF NYHA IV
 Ass: Etiologi : IHD  Pharmacology

Anatomi : LVH consentric, LA B-Blocker : Bisoprolol 2,5 mg 1x1

Dilatation Diuretic (Furosemide ) 2x1(20mg)
Fungsional : NYHA III to reduce
• IP Dx : BNP, Pro-BNP ACE-1 (Captopril) 2x1 (6,25mg) -
 IP Tx : > to promote remodeling

 Non Pharmacology
 Low Fat Intake

 Low Salt intake

 Reduce activity

 High fiber Diet

 O2 (2tpm)
Ip. Mx : Vital sign, ECG, INR, SpO2

Ip. EX :

 Bed Rest/Restriction of physical activity

 Reducing Emotional stress

 Sit position or a half sleep position

 educating about etiology, risk factor, and

explain about sign and symptom of CHF

 Routine control and takking a medication

 Do not carry out excessive activities

Acute Coronary Syndrome
• Ass : Acute Coronary Syndrome
• IP Dx : Troponin I Serial
• Ip Tx : Aspilet 80mg 1x1
CPG 75 1x1,
Bisoprolol 1x1
Statin : artorvastatin 20 mg x 1 or 40 mg x 1,
for prevent plaque
Anticoagulant : heparin
Mx : APTT
• IpMx : Vital sign, ECG, laboratory examination and
troponin I
IpEx :
oReducing emotional stress
oReducing of physical activity
oDiet low fat
oControl blood pressure
1. Assesment
• Acute Complication: Hipoglycemia, Hyperglicemia (KAD,SHH)
• Chronic Complication: Makroangipati (PJK, CVD, PAD) Mikroangiopati
(retinopati, nefropati, neurpati)
2. IP Dx : GDP, GD2P, dan HbA1C
• Angiografi, ABPI, Funduskopi, EMG, Microalbumin test, CT-scan
2. IP Tx :
• Non pharmacology : medical nutrition therapy
• Pharmacology: Humalog 3 x 10 U
4. Ip. Mx : Vital sign, clinical manifestation
(hypoglycemia/hyperglycemia), blood glucose, HBA1c, ureum, kreatinin
5. Ip. Ex :
• Explain to patients about the condition, therapy, and complication that
may occur
• Explain how to check blood glucose routin
• Education of hypoglycemia sign and how to treat
• Reduce intake of food with high index glycemia
• Explain how to use insulin
Assesment
Cardiovascular risk
IP Dx
- triglyceride, cholesterol
IP Tx
Non pharmacology
Medical Nutrition Therapy
Lifestyle Modification
IP Mx
a. Body Weight
b.GDS
c. Lipid Profile
d.Uric Acid level
IP Ex
• Routine exercise
• Avoid excessive saturated
fatty acid intake