CBD

Case Base Discussion

Advisor : dr. H. M. Saugi Abduh, Sp.PD, KKV, FINASIM

Oleh : Muhammad Charis Mwardi (30101407246)
  Name : Ny. L

 Age : 56 years old

 Gender : Female

 Religion : Moslem

 Job : food seller

Patient  Address : Pondok Raden Patah I Rt

Identity 08/Rw 09, Demak

 MR number : 01270xxx

 Room : Baitul Izzah 1

 Entry date : July 9 th, 2018

 Date out : July 12 th, 2018 2

 History of Present Illness

Patient came to Emergency Room Islamic of

Hospital Sultan Agung Semarang. She
complained about her palpitation and chest
discomfort since one hour before arrival to
Main Problem hospital. This condition was persisting until the
patient came to hospital. The palpitation and
chest discomfort risen when patient was at
palpitation rest. She has been having symptom for the last
six month ago. She had another complained
like sweating and shortness of breath.

3
 Sistemic 1 ■ Onset
■ One hour

Anamnesis 2 ■ Location
■ Left chest

3 ■ Chronology
■ Palpitation and chest discomfort risen when patient was at
rest.
4 ■ Quality and Quantity
■ The palpitation and chest discomfort was persisting until the
patient came to hospital.
Chief Complains 5 ■ Modification factor
■ No modification factors
Palpitation
6 ■ Comorbid complains
■ sweating, shortness of breath

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■ HISTORY OF PREVIOUS
ILLNESS ■ Family History ■ Socio-economic
History
■ Hypertension (-) ■ Hypertension history ■Hospital cost certified by
■ DM (-) (+) ■“BPJS-PBI”
■ Alkohol (-) ■ DM history (-)
■ Smooking (-)
■ Allergy (-) 5
 PHYSICAL
EXAMINATION

6
General Status
◦ Awareness : Composmentis (GCS 15)
◦ Antropometri :
◦ Weight : 59 kg
◦ Height : 155 cm
◦ BMI : 24 INTERPRETATION :
normal
7
 In Emergency room
o BP : 124/95 mmHg o BP : 120/70 mmHg
o HR : 171x/menit o HR : 78x/menit
o RR : 36x/minute o RR : 20x/minute
o Temp : 36,6o C o Temp : 36,5o C

VITAL SIGN
INTERPRETATION : INTERPRETATION :
Takikardi Normal
tachypnea
 Lung Examination

INSPEKSI ANTERIOR POSTERIOR

■ Ad urbanitas argumentum sea. Ut has tota ridens oblique, ad elitr
aliquam mentitum his. Duo in sale audiam incorrupte. Sea at

1 spider nevi
accusamus rationibus, ad saepe facilis cum, convenire consequat
conceptam est ne.

Static ■
RR : 20x/min, Hyper pigment (-),
Quas invidunt ad nam, his reque molestiae te. Nam cu definitiones
definitionem, et oblique detracto electram nec.
RR : 20x/min, Hyper pigment
(-), atrophy Pectoral Muscle (-), Hemithoraks D=S, ICS (-),spider nevi (-), Hemithoraks D=S,
Normal, Diameter AP <
2 LL ICS Normal, Diameter AP < LL

Dynamic Up and down of hemitoraks D=S, abdominothorakal Up and down of hemitoraks D=S, abdominothorakal
breathing (-), muscle retraction of breathing (-), breathing (-), muscle retraction of breathing(-),
3
retraction ICS (-) retraction ICS (-)

Palpation Palpable pain(-), tumor (-), Arcus costae angle < 900, Palpable pain (-), tumor (-), Arcus costae angle < 900,
4
enlargement of ICS (-), Chest Expantion (normal), enlargement of ICS (-), Chest Expantion (normal), Stem
Stem fremitus D=S (normal) fremitus D=S (normal)

Percussion sonor 5 sonor

Auskultation Vesicular (+), Whezzing (-), Ronchi dibasal(-) Vesicular (+), Whezzing (-), Ronchi dibasal(-)
INTERPRETATION :
9
Normal
Inspection : Ictus cordis isnt seen.
Palpation : thrill (-), epigastric pulse (-),
parasternal pulse (-), sternal ■ Auscultation
lift (-).
 Aortal valve : S1 & S2 standard, additional
Percussion : dull sound
sound (-)
- Upper borderline of heart: ICS II left sternal line
 Pulmonary valve: S1 & S2 standard, additional
- Waist of heart : ICS III left parasternal line
sound (-)
- Lower right borderline of heart : ICS V right
sternal line  Tricuspid valve : S1 & S2 standard, additional

- Lower left borderline of heart : ICS VI 1 cm sound (-)

from left mid clavicle line  Mitral valve : INTERPRETATION

S1 & S2 standard, additional
:
sound (-) Left ventrikel hipertrofi
10
 Abdominal Examination

Inspection
bulging(-), hyperpigmentation (-), sycatric(-), striae(-),
vein distention (-), caput medusa (-).

Auscultation
peristaltic (+) normal

Percussion
Timpani (+), side of deaf (-), shifting dullness
(-) INTERPRETATION :
•Liver : dullness (+), right liver span 10cm, left
normal
liver span 6 cm Palpation
•Spleen : Traube space percussion (+) •Superfisial : tight (-), mass (-), epigastrial pain (-)
•Deep : abdominal pain (-), liver (+) and spleen palpable
(-) renal (-) Murphy’s sign (-)
11
 EXTREMITY SUPERIOR INFERIOR
Oedem -/- -/-
Cold -/- -/-
Physiology Reflex +/+ +/+
Pathology Reflex -/- -/-
Icteric -/- -/-

INTERPRETATION :
Normal
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LABORATORIUM

13
 HEMATOLOGY dan IMUNOSEROLOGI

Hematology 9 July 2018 Nilai rujukan Keterangan

Hemoglobin 15,7 11,7-15,5 g/dl High

Hematokrit 45,3% 33-45% High
Leukosit 9,34 3,6-11ribu/uL Normal
trombosit 182 150-440 ribu/uL Normal
(Imunoserologi) Reaktif Non Reaktif
HbsAg

INTERPRETATION :
Polisitemia, HbsAg +
 KIMIA DARAH
Kimia 10 July 2018 Nilai rujukan Keterangan

Natrium 142.0 135-147 mmol/L Normal

Kalium 3.92 3.5- 5 mmol/L Normal
Chloride 102.9 95 – 105 mmol/L Normal
Calcium 7.7 8.8 – 10.8 mg/dL Low
Cholestrol 157 <200 mg/dl Normal
trigliserid 53 <160 mg/dl Normal
HDL 49 37 – 92 mg/dl Normal
LDL 103 60 - 130 mg/dl Normal
INTERPRETATION :
Uric acid 5.3 2.6 – 5,7 mg/dl Hypocalcemia
Normal
 X-RAY
(9 july 2018)

Cor : CTR >50%, apeks bergeser ke

laterocaudal, elongasio aorta.
Pulmo : Corakan bronkhovaskular normal
Tak tampak bercak pada paru,
Hilus tak melebar
Sinus kostofrenikus dan Diafragma
normal

Kesan :
COR : CARDIOMEGALY (LV),
ELONGASIO AORTA
PULMO : TAK TAMPAK KELAINAN
ECG

17
9 July 2018
( 20.05)
 Interpretation
Rhytm : junctional
9/7/18 Regularitas : Reguler
Frekuensi : 1500/9 = 166 x/menit  takikardi
Axis : NAD
Zona Transisi : V4 ( normal )
Gelombang P : tidak bisa diidentifikasi
Interval PR : tidak bisa ditentukan
Komplek QRS : 0,08 s ( normal )
Gelombang Q : tidak ada Q patologis
Segmen ST : tidak ada ST elevasi maupun depresi
Gelombang T : T inversi ( - ), tall T (-), T flat (-)

INTERPRETATION :
SVT
9 July 2018
(20.50)
 Interpretation
Rhytm : junctional
9/7/18 Regularitas : reguler
Frekuensi : 1500/25 = 60 x/menit ( normal )
Axis : lead I (+), avf (+) (NAD)
Zona Transisi : tidak ada
Gelombang P : tidak dapat dinilai
Interval PR : tidak dapat dinilai
Komplek QRS : 0,04 di lead II ( normal )
Gelombang Q : tidak ada q patologis
Segmen ST : tidak ada ST elevasi maupun depresi
Gelombang T : T inversi ( - ), tall T (-), T flat (-)

INTERPRETATION :
junctional
11 July 2018
( 08.05)
 Interpretation
Rhytm : sinus
11/7/18 Regularitas : reguler
Frekuensi : 1500/30 = 50 x/menit ( bradikardi )
Axis : lead I (+), avf (+) (NAD)
Zona Transisi : tidakada
Gelombang P : tinggi 0,1 mV: , lebar 0,08 s (normal)
Interval PR : 0,12 (normal )
Komplek QRS : 0,04 (normal)
Gelombang Q : tidak ada Q patologis
Segmen ST : tidak ada ST elevasi maupun inversi
Gelombang T : T inversi ( - ), tall T (-), T flat (-)

INTERPRETATION :
Sinus bradikardi
ECHOCARDIO
GRAPHI

24
 11/7/18
• Heart Chamber Dimention : LA Hypertrofi
• LV Wall : IVS Thickness
• Wall motion : global normokinetik
• Valve heart : normal
• Sistolic LV Function : EF 70%
• Sistolic RV Function : TAPSE 23 mm
• Diastolic LV Function : E/A >1

• Conclution:
• Global normokinetik
• Sistolic LV and RV function normal
• Diastolic LV function normal
• Dilatasi LA, hipertrofi intraventrikular septal
27
 Abnormal Data
History Taking
1. Chest discomfort
2. Palpitation
3. Sweating ECG
Lab
4. Shortness of breath 10. SVT
5. Same symptom in 9. Hypocalcemia 11. Junctional
past
6. Family ( HT
diseases)

Physical Examination
7. Heart rate in
emergency room
171 x/menit.
8. RR 36x/menit
 Problem List

Hypocalcaem SVT
ia

10 1,2,3,4,5,6,7,8,11,12
 SVT
1. Assessment :
Electrolite disorder 4. Initial Plan of Monitoring
Drug induced - ECG, vital sign
VHD
5. Initial Plan of Education :
Psikosomatis
2. Initial Plan of Diagnosis : Reducing Emotional stress
- Routine consumption drugs
3. Initial Plan of Therapy : Maintain ideal weight
Non-pharmacology Mild exercise regularly
– O2 (2lpm)
Pharmacology
• IV adenosine ( initial dose 6 mg IV rapid bolus ), (
maintenance 12 mg IV )  until the HR is <100
• Propanolol ( initial dose 1 mg IV over 1 minute,
maintenance 1 mg 1 until 3 mg )
• Verapamil  maintenance 80mg po 2-3x1
Supraventricular tachycardia symptoms
39
40
41
42
 HYPOCALCAEMIA
1. Assessment :
-
2. Initial Plan of Diagnosis : 4. Initial Plan of Monitoring
-
- Calcium serum level
3. Initial Plan of Therapy
• Ca gluconase IV 100mg (1 amp)  given until
Ca serum level is 8.8-10.8 mg/dL 5. Initial Plan of Education :
Diit high calcium
Causes of hypocalcaemia
DEFINITION OF HYPOCALCAEMIA
 CALCEMIA
PHYSIOLOG
Y
Thank
you

52
 HbsAg +
1. Assessment :
– Chronic hepatitis
– inactive suffer
– Resolved hepatitis infection 4. Initial Plan of Monitoring

1. Initial Plan of Diagnosis :

– DNA VHB serum 5. Initial Plan of Education :
– HbeAg, anti HbeAg Explain about hepatitis B disease, like clinical
– Liver function test manifestation
– USG
3. Initial Plan of Therapy
■ Curcuma 2x 500mg