Case Based Discussion

Gagal Jantung dan TB Paru

Diajukan Guna Melengkapi Tugas Kepaniteraan Klinik

Bagian Ilmu Penyakit Dalam
RS Islam Sultan Agung Semarang

Oleh :
Fitri Aulia Ananda
012116397

Pembimbing :
dr. Lusito, Sp.PD

A. PATIENT IDENTITY
Name

: Mr. H

Age

: 50 y.o

Sex

: Male

Religion

: Moslem

Job

: Swasta

No. Medical Record

: 01264481

Address

: Kp. Batiksari 747 Rejomulyo, Semarang

Room Care

: Baitul Izzah 2

Date in

: 26 Sept 2015

Date out

: 7 Okt 2015

Status Care

: JKN NON PBI kelas III

B. CHRONOLOGY
When the date was 26th of September 2015 , Patient came to Internist Clinic
Sultan Agung Hospital with tightness. He complained feel tightness while
walking . Patients come about to check up on her illness. Approximately one
week already complained of this. He also should wake up at night besause of
cough and tightness. He had cough with thick phlegm since 3 weeks. He had been
given the drug from the stall, but not cured. His weight decreased approximately
for one month.

C. ANAMNESIS
General

: weak

Skin

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

Head

: headache (-)

Eyes

: blurred vision (-), red eyes (-), icteric sclera (-/-)

Ears

: hearing loss (-), discharge (-)

Nose

: nosebleed (-), discharge (-)

Mouth
Throat

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

: pain swallow(-), hoarseness (-), difficult in
swallowing (-)

Neck

: enlargement of the gland (-), nape pain (-)

Chest

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

Cardiac

: chest pain (+)

Digestive

: abdominal pain (-), decreased appetite (+), loss

weight (+), nausea (-), vomiting (-)

Musculosceletal

: weak (-), rigid (-), back pain (-)

Extremity

: oedem inferior extremity (-)

History of previous illness

Thypoid fever history (-)

Hypertension history (-)
Heart disease history (-)
DM history (-)
Smoking (+)
Cough (+)
Maag (-)
Allergy (-)

Familys history of disease

Hypertension history (-)
DM history (-)
Cardiovascular (-)
Sosio-Economic History :
Hospital cost insuranced by BPJS (NON PBI Class III)

D. PHYSICAL EXAMINATION
a. VITAL SIGN
i. BP = 130/80 mmHg
ii. HR = 84 x/menit
iii. RR = 28 x/menit
iv. T
= 36,5 0C
b. BMI
i. BB = 48 Kg
ii. TB = 160 cm
iii. BMI = 18,7 (Normal)
c. THORAX
INSPEKSI

ANTERIOR

POSTERIOR

Static

Hyperpigmentation (-), tumor

(-), inflammation (-), spider nevi
(-), Hemithorax D=S

Hyperpigmentation (-), tumor(-),

inflammation(-), spider nevi (-),
Hemithorax D=S.

Dinamic

hemithorax movement D=S

hemithorax movement D=S

Palpation

Palpation pain (-), tumor (-),

normal ICS, Stem fremitus D=S

Palpation pain (-), tumor (-),

normal ICS, Stem fremitus D=S

Percussion

Dextra: sonor
Sinistra : redup

Dextra: sonor
Sinistra : redup

Auscultation

Decrease of vesicular sound (-)

ronchi (+/+), wheezing (-/-)

Decrease of vesicular sound (-)

ronchi (+/+), wheezing (-/-)

d. CARDIAC
i. Inspection : Ictus cordis can t be seen.
ii. Palpation : Ictus cordis is palpable at SIC V linea mid
clavicula sinistra, thrill (-), pulsus
epigastrium (-), pulsus para-sternal (-), sternal lift (-).
iii. Percussion : dull sound
1. Upper borderline of heart
: SIC III linea sternalis
sinistra
2. Waist of heart
: SIC IV linea
parasternalis sinistra

3. Lower right borderline of heart : SIC IV linea sternalis

dextra
4. Lower left borderline of heart : SIC V linea axilaris
anterior sinistra
iv. Auscultation
1. Aorta valve : S1 & S2 standart, additional sound (-)
2. Pulmonal valve : S1 & S2 standart, additional sound (-)
3. Trikuspidal valv : S1 & S2 standart, additional sound (-)
4. Mitral valve : S1 & S2 standart, additional sound (-)
e. ABDOMEN
Inspection
: flat of surface(-), sycatric(-), striae(-),
enlargement of vena (-), caput medusa (-)
Auscultation : peristaltic (+)
Palpation
o Superfisial: supel, massa (-)
o Deeper
: abdominal pain (-), hepar (normal size),
lien (S0), Murphys sign (-)
Percussion
: tympany, shifting dullness (-)
o Hepar : normal size
o Lien
: troube space percussion (+)
f. EXTREMITIES
Ekstremitas

superior

inferior

- Oedem

-/-

-/-

- cold extremities

-/-

-/-

- Icteric

-/-

-/-

E. LABORATORY EXAMINATION
examination

result
result

Hb

12,6 g/dl

Ht

36.3 %

Leukosit

10,9 ribu/uL

Trombosit

342 ribu/uL

Mikrobiologi
BTA (Sputum)

2+

F. ECG

Irama : sinus
Regularitas : reguler
Frekuensi : 100 x/ menit
Axis : LAD
Zona Transisi V6 ( clockwise)
Gel P : 0,06 s
QRS : 0,12 , S persisten di V5
Segmen ST : isoelektris
Gel T : T inverted di V1 dan V2
Kesan : LAD , Iskemi lateral kanan, LVH

G. RADIOLOGY

COR : CTR > 50% . Apeks bergeser

ke laterokaudal

Kesan : Kardiomegali (LV)

Pulmo : Corakan bronkovaskular

meningkat. Tampak bercak pada
lapang atas, tengah dan bawah paru
kanan kiri.

H. DATA ABNORMALITIES
Anamnesis :
1. Dispneu
2. Weak
3. Headache
4. Cough
5. Loss weight
Physical Examination:
6. Percusion in cor : cardiomegali
7. Auscustation ronkhi
Advance Examination:
8. BTA = 2+
9. Radiology : CTR > 50% Cardiomegaly
10. Radiology Bronchovasulary imaging

I. PROBLEM LIST

J. CHF

Ass

: IHD,LVH, LAH

IP Dx

: ECG, X foto thorax, Echocardiograph

IP Tx

:
Non pharmacology
Low Salt intake
Reduce activity
High fiber Diet
Pharmacology
Infus RL 10 tpm
Nasal O2 3lt/minute
Captopril 2x12,5mg
Spironolakton 1 x 25 mg
Bisoprolol 1x2,5mg
Digoxin 0,25 mg (2x1)

IP Mx: Vital sign, ECG,

IP Ex :
Tell about her illness
Bed rest
Reduce salt intake
Reducing intake of water
Stop smoking
K. TUBERCULOSIS
Ass
: IP Dx
: Px Sputum SPS, X Foto Thorax
IP Tx
:
Non pharmacology
food nutrition , bed rest
Pharmacology
OAT FDC 2HRZE + 4(HR)3
RHZE (150/75/400/275) 3x 1 (56 hari)
RH (150/150) 3 tablet , 3 kali seminggu (16 minggu)
IP Mx : sputum test ( 2 months , 5 months)
IP Ex
:
Tell about her illness

Prevent of spreading ( covering when cough , put the sputum into a

chamber with sand)
Consumption drug regularly
Take a rest
Stop smoking