CBD

Case Base Discussion

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

Oleh : Agata Nudiayona
 Name : Tn Salim
Age : 57 tahun
Gender : Laki - laki
Religion : Muslim
Job :-
Identitas Pasien Address : Genuksari, rw 3 rt 3
MR number : 010xxxxxx
Room : Baitul Izzah 1
Entry date : 28 November 2018
Date out : 30 November 2018

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 History of Present Illness

History Taking ± 1 hari sebelum masuk rumah sakit, pasien l

aki- laki 57 tahun datang dengan keluhan ses
ak nafas setelah melakukan pekerjaan berat.
Sesak nafas terasa sulit bernafas dan seperti
tertindih beban berat. Keluhan dirasakan tiba
Main Problem 2 setelah pasien beerja berlebihan. Sesak me
mberat saat merebahkan badan dan setelah

Sesak nafas akifitas, membaik saat beristirahat dan memi

num obat. Keluhan lain adalah batuk terus m
enerus, pusing, ekstremitas bengkak dan lem
ah
 ■ Onset
1 ■ 1 hari sebelum masuk RS

Systemic Ana ■ Location

■ Seluruh dada
mnesis 2

■ Chronology
3 ■ Beraktifitas  Sesak

■ Quality and Quantity

Patient Complained 4 ■ Seperti tertindih

■ Modification factor
DISPNEU 5 ■ Memburuk saan berbaring, membaik saat seten
gah duduk
■ Comorbid complains
6 Lemah, pusing, batuk

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■ HISTORY OF PR ■ SOCIO-ECONOMI
EVIOUS ILLNESS ■ FAMILY HIST C HISTORY
ORY
■ Hypertension history (-)
■ Hipertensi (+) ■ Gejala sama (+) 2 ■ Hospital cost certified by
■ Jantung (-) tahun ■ DM history (+)
“BPJS-non PBI”
■ Heart disease (-)
■Merokok (+)

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PHYSICAL
EXAMINATION

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General Status
Awareness : Composmentis (GCS 15)
Antropometri :
◦Weight : 70 kg
◦Height : 170 cm
◦BMI : 70/2,89 = 24,2 INTERPRETATION :
Normoweight
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 In Emergency Room In Baitul Izzah
o BP : 100/60 mmHg o BP : 103/75 mmHg

o HR : 116x/menit o HR : 111x/menit

o RR : 29x/minute o RR : 30x/minute

o Temp : 37,4o C o Temp : 37,5o C

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VITAL SIGN
INTERPRETATION : INTERPRETATION :
NORMOTENSION, NORMOTENSION,
TACHYCARDI, DYSPNEU TACHYCARDI, DISPNEU
 Lung Examination
INSPEKSI ANTERIOR POSTERIOR
Static RR : 30x/min, Hyper pigment (-), spider neivy RR : -, Hyper pigment
(-), atrophy Pectoral Muscle (-), Hemithoraks
1 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, abdominothorakal
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breathing (-), muscle retraction of breathing (+/+), breathing (-), muscle retraction of breathing(-),
retraction ICS (+/+) retraction ICS (-)
Palpation 3 angle < 900,
Palpable pain(-), tumor (-), Arcus costae Palpable pain (-), tumor (-), Arcus costae angle < 900,
enlargement of ICS (-), Chest Expantion (normal), Stem enlargement of ICS (-), Chest Expantion (normal), Stem
fremitus D≠S fremitus D≠S (normal)
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Percussion sonor sonor
Auskultation Vesicular (+), Whezzing (-), Ronchi basal(+/+) Vesicular (-), Whezzing (-), Ronchi basal(+/+)
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INTERPRETATION : Infiltrat 9
Inspection : Ictus cordis isn’t seen. Cardiac Examination
■ Auscultation
Palpation : thrill (-), epigastric pulse (-), p
arasternal pulse (-), sternal lift (-).  Aortal valve : S1 & S2 standard, additional

Percussion  : timpani sound sound (-)

- Upper borderline of heart : ICS II left stern  Pulmonary valve: S1 & S2 standard, additio

al line nal sound (-)

- Waist of heart : ICS III left parasternal line  Tricuspid valve : S1 & S2 standard, additio
- Lower right borderline of heart : ICS V righ nal sound (-)
t sternal line
 Mitral valve : S1 & S2 standard, additional
- Lower left borderline of heart : ICS V 1 c
sound (+), gallop S3
m from left mid clavicle line

INTERPRETATION :
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Gallop S3
 Abdominal Examination

INTERPRETATION :
Inspection Normal
Bulging(-), hyperpigmentation (-), sycatric(-),
striae(-), vein distention (-), caput medusa
(-). Icon Icon

Auscultation
BU peristaltic (+) 20x/menit=normal

Percussion
- Timpani (+), side of deaf (-), shifting d
ullness (-) Icon Icon

- Liver : dullness (-), right liver span 9 c

m, left liver span 6 cm
- Spleen : Traube space percussion (+)
Palpation
•Superfisial: tight (-), mass (-), epigastrial pain (-)
•Deep : abdominal pain in epigastrium (-), liver (-) and
spleen palpable (-) renal (-) Murphy’s sign (-)
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 Extremity Examination

EXTREMITY SUPERIOR INFERIOR

Oedem -/- +/+
Cold -/- -/-
Physiology Reflex +/+ +/+
Pathology Reflex -/- -/-
Icteric -/- -/-
INTERPRETATION :
Oedem Inferior extremity
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LABORAT Icon

ORIUM
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 HEMATOLOGY

Hematolog
Nilai rujukan Keterangan
y
Hemoglobin 11,8 11,7,2-17,3 g/dl Normal
Hematokrit 33,5% 33-45% Normal
Leukosit 8,26 3,6-11ribu/uL Normal
Trombosit 332 150-440 ribu/uL Normal
Gol Darah B/Positif

INTERPRETATION :
Normal
 BLOOD CHEMISTRY
Kimia Nilai rujukan Keterangan
Natrium 140,9 135-147 mmol/L normal
Calium 3,93 3.5- 5 mmol/L normal
Chloride 99,2 95 – 105 mmol/L normal
SGOT 21 0-50 normal
SGPT 20 0-50 normal
CKMB 17 <24 normal
Ureum 27 10-55 normal
Kreatinin 0,65 0,7-1,3 normal
High Sensitif 9,2 - <19 = tidak ada nyeri dada normal
Troponin - >100mg/Dl = Rule in
- 19-100

INTERPRETATION: Normal
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ECHO

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ECHOCARDIOGRAPHI
EF = 24%
%FS = 12%
Kesan
- Global hipokinetik
- Fungsi LV sistolik menurun
- Fungsi RV sistolik baik
- Dilatasi LA dan LV
- TR moderate PH mild MR Moderate
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X-RAY

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 X RAY

Cardiomegaly (suspek LV, LA, RA)

CTR = 7+7,5/16= 85%
Acute Edem Pulmo

Dull angle
Meniscus
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EKG

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 Interpretation
Rhytm : Tidak teratur
Regularitas : Ireguler
Frekuensi : 8x10=120x/menit
Axis : RAD
Zona Transisi: -
Gelombang P: 0,08
Interval PR: 0,10
Komplek QRS : 0,06 s ( normal ), ditemukan RBBB di V1,V2,V3
Gelombang Q :-
Segmen ST : 0,28
Gelombang T: T inverted III, VI

INTERPRETATION :
Atrial Fibrilasi, OMI
 Abnormal Data
History Taking
1. Sesak nafas
2. Pusing Physical Examination ECG
3. Batuk 6. Gallop S3 9. AF Normo respond
4. Riwayat Hipertensi 7. Basal ronchi 10. Old Infark miokard
5. Palpitasi 8. Extrremity oedem

X-RAY
11. Cardiomegaly (suspect LV, LA, RA), ECHOCARDIOGRAPI
Elongasio aorta 13. EF = 24% (Global hipokinetik)
12. Acute Edem Pulmo
 Problem List

CHF AF

1,8,13 9

IHD HHD
EDEM PULMO

10 6,11 1,3,7,12
 Pharmacology

CHF NYHA I • B-blocker (Bisoprolol 1,25–10mg/day)

• Furosemid 1x1
• Spironolacton 25mg 1x1
1. Assessment :
• Bioprexun 1x1
A. RF: Hipertensi
• V-Blok 2x1
B. Anatomy : LV, LA, RA
• Nitrokaf R 2x1
C. Functional : NYHA I
D. Etiology : AF, Infark miocard, HHD 4. Initial Plan of Monitoring
2. Initial Plan of Diagnosis : ■ - ECG, vital sign, INR, APTT/PTT, CHA2
BNP DS2-VASc and HAS-BLED, electrolit of
potasium, renal function
3. Initial Plan of Therapy :
Non-pharmacology 5. Initial Plan of Education :
– O2 (4 lpm) Reducing Emotional stress
– Bedrest Routine consumption drugs
– Low protein intake
Avoid risk factors
 ATRIAL FIBRILLATION
1. Assessment :
Etiology: infarc miokard, HF, valvular he
art disease (TR, MR) 4. Initial Plan of Monitoring
Risk Factor: HHD
Complication: stroke, thromboembolism
ECG, vital sign, INR, APTT
2. Initial Plan of Diagnosis : 5. Initial Plan of Education :
CHA2DS2-VASc for stroke prevention Reducing Emotional stress
3. Initial Plan of Therapy
Routine consumption drugs
• Digoxin 0,5-0,8 mg/ml
Avoid risk factors
• B-blocker (Bisoprolol 1,25–10mg/day)
• Antagonist Vit – K (suspect VHD)
• Aspilet
 IHD
1. Assessment : b. Pharmacology
• Etiology Bisoprolol 1,25-10ml
– CAD ISDN 5 mg (attack)
Atorvastatin 20 mg 1x1
2. Initial Plan of Diagnosis :
Troponin I 4. Ip.Mx :
CKMB
Angiography • ECG
3. Initial Plan of Therapy
5. Ip.Education :
a. Non Pharmacology
• Low Fat Intake • Reducing Emotional stress
• High Fiber diet • Reducing eat that food contain high cholesterol
• Exercise
• Healthy eating habits
 HHD
1. Assessment : b. Pharmacology
Anatomi : LVH Captopril 12,5 mg 3x1
Fungsional : Diastolic disfunction Bisoprolol 1,25-10ml
2. Initial Plan of Diagnosis :
4. Ip.Mx :
-ekg
3. Initial Plan of Therapy • ECG

a. Non Pharmacology 5. Ip.Education :

• Low Fat, salt Intak
• Decrease high exercise • Reducing Emotional stress
• Healthy eating habits ->stop smoke
• Reducing eat that food contain high cholesterol
 EDEM PULMO
Pharmacology
1. Assessment :
• Furosemid 1x1
A. Etiologi : Kardiak (CHF)
• Spironolacton 25mg 1x1
Non Kardiak
2. Initial Plan of Diagnosis : 4. Initial Plan of Monitoring
EKG ■ - vital sign, x foto thorax
Enzim Jantung 5. Initial Plan of Education :
Darah rutin (analisis PCO2, PO2) Mengurangi aktifitas berat
3. Initial Plan of Therapy : Posisi tidur 30-40o
Non-pharmacology
Mengkonsumsi obat teratur
– O2 (4-8 lpm)
– Bedrest
– Low protein intake
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