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CASED BASED DICUSSION

Internal Department of Sultan


Agung Islamic University
Advisor:
dr. H. M. Saugi Abduh, Sp.PD KKV
FINASIM
By :
Nita Septiantika

(01.208.5736)

Patient Identity
Name
: Mr. P
Age
: 55 years old
Sex
: Male
Religion
: Islam
JOB
: Wiraswasta
No. Medical record : 01287509
Address
: Wedung - Demak
Room care
: Baitul Izzah 1 409.1
Date in
: May 31th 2016
Date out
: June 5 th 2016

The Examination`s Results


ANAMNESA
Main Problem :
Dyspneu and weakness
History of Present Illness :
Patients come to the Emergency Room Islamic Hospital of
Sultan Agungs with complaints of dyspneu and weakness
since a week ago and worsening since one day ago. She
complain that her dyspneu happens everyday and has
restricted her activity. Dyspneu always appeared even when
resting. Another symptom are nausea, vomitus, and
decreased appetite

History of Illness
History of previous illness :
Hypertension history (+)
Heart disease history (+)
DM history (+)
Kidney disease history (+)
Hemodialisa history (+)
Asthma history (-)
Familys history of disease :
Hypertension history (-)
Heart disease history (-)
DM history (-)
Asthma history (-)

Systemic Anamnesis
General
Skin

: dyspneu (+), weakness (+), fever (-)


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

Head

:headache (-)

Eyes
:blurredvision(-), red eyes(-),conjungtiva anemic (+/+),
ictericsclera
(-/-)
Ears

:discharge(-), hearingloss(-)

Nose

:nosebleed(-),discharge (-)

Mouth

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

Throat

:painswallow(-), hoarseness(-), difficult in swallowing(-)

Neck
: trakhea deviation (-), Lymph Hypertropy (-), enlargement
ofthe gland(-)
Chest
Cardiac

: cough(-),sputum(-),blood(-)
:chest pain(-),palpitations(-)

Digestive
:abdominal pain (-), diarrhea(-), decrease appetite (+),
nausea(+),
vomiting(+), defecate/micsi (+/+)
Musculoskeletal
: weak(-),rigid(-),back pain (-)
Extremity

: oedem of lower extremity (-/-), Oedem of upper extremity

Physical Examinations

General Status
General

: Weakness and Dypsneu

Awareness

: Composmentis

Vital Sign

BP = 171/75mmHg
Pulse
= 83 x/menit
RR = 32 x/menit
t
= 36.5 0C

Status Present

Sex
: Mmale
Age
: 55 y.o
Weight : 60kg
Height : 163 cm
BMI
: BB(kg)/TB(m)
= 60 kg/(1,63 m)
= 22.58 (normoweight)

Chest Examination-Lung
EXAMINATION

ANTERIOR

POSTERIOR

Inspeksi

RR : 22x/min, thoracal
breathing,Hyperpigme
ntasi (-), spider nevi
(-), atrofi M. Pectoralis
(-), Hemithoraks D=S,
ICS Normal, Diameter
AP < LL

RR : 22x/min, thoracal
breathing,
Hiperpigmentasi (-),
spider nevi (-),
Hemithoraks D=S, ICS
Normal, Diameter AP <
LL

Dinamic

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

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

Palpation

Palpation pain (-),


mass (-), Sterm
fremitus D=S

Palpation pain (-),


mass (-), Sterm
fremitus D=S

Sonor (+)

Sonor (+)

Static

Percution
Auskultation

Vesicular (+),
Whezzing
Interpretation : lung
oedem (-), Ronchi
(+)

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

THORAX COR
INSPECTION
Ictus cordis can be seen
PALPATION
Ictus cordis is palpable at ICS VI, from linea axillaris anterior
sinistra, thrill (-), pulsus epigastrium (+), pulsus parasternal
(+), sternal lift (+)
PERCUTION
Upper borderline
Waist

:
:
:
:

ICS
ICS
ICS
ICS

II left sternal line


III left parasternal line
V right sternal line
VI linea axillaris anterior sinistra

Lower right
borderline
Lower left
borderline
AUSCULTATION
Interpretation : Cardiomegali
S1 & S2 (+), Additional sound (-),

ABDOMEN
1.Inspection

Simetrics, sycatric(-), striae(-), enlargement of vena


(-), caput medusa (-), spider nevi (-)

2. Auskultasi

peristaltic (+), aorta abdominal bruit (-), A. Lienalis, A.


femoralis(-)

3. Percussion

Shifting dullness(-), undulation test (-), hepar deaf(-)


liver span dextra 11 cm, liver span sinistra 6 cm,
troub space (+)
mass (-), pain (-) , hepatomegali (-), hepar, kidney &
lien arent palpable, Splenomegali (-), Murphys sign
(-)

4. Palpation

Interpretation : Normal

EKSTREMITIES
Superior

Inferior

Oedem

-/-

-/-

Akral dingin

-/-

-/-

Reflek fisiologis

+/+

+/+

Ikterik

-/-

-/-

Ekstremitas

Laboratoriums Examination
01/06/2016

Hematologi

Hb

8.9 g/dl (L)

Ht

28.3 % (L)

Leukosit

14,31 ribu/uL (H)

Trombosit

180 ribu/uL

Ureum

305 mg/dl (H)

01/06/2016

Kimia

Blood Creatinin

9.56 mg/dl (H)

Natrium

132.6 mmol/L (L)

Kalium

8.34 mmol/L (H)

Chlorida

111.3 mmol/L (H)

Calcium

9.1 mmol/L

Magnesium

2.4 mmol/L

GDS

337 (H)

Interpretation :
Anemia
Leukocytosis
Azotemia
Hyponatremia
Hypercalemia
Hyperchlorida
Hyperglikemia

02/06/2016

Hematologi

Hemoglobin

9.1 g/dl (L)

Hematokrit

27.2 % (L)

Leukosit

11.70 ribu/uL (H)

Trombosit

185 ribu/uL

Ureum

122 mg/dl (H)

Blood Creatinin

4.22 mg/dl (H)

04/06/2016

Hematologi

Ureum

186 mg/dl (H)

Blood Creatinin

4.64 mg/dl (H)

GFR/LFG
(140-age) x Weight
72 x creatinin plasma
(140-55) x 60
72 x 9,56
5.100 = 7,409
688,32

Interpretation : CKD stage V

ECG

EKG Interpretation
1.
2.
3.

Irama
Frekuensi
Axis

: Sinus
: 37x/mnt
: Lead 1 (-), AFV (-) deviasi kanan
ekstrim
4. Zona Transisi
:5. Morfologi
- P Wave
:- Interval PR
: 3 kk = 0,12 sec
- Q Wave
: Q patologis (-)
- Kompleks QRS
: 5 kk = 0,2 sec melebar Lead II,
Lead III, AVR, AVL, AVF, V3, V4, V5, V6
- Segmen ST
: ST elevasi (-), ST depresi (-)
- T Wave
: T tall (+) V4, V5, V6
T inverted (+) AVR, AVL, V1
Interpretation : RVH, RBBB, Hipercalemia

EKG Interpretation
1.
2.
3.

Irama
Frekuensi
Axis

: Sinus
: 51x/mnt
: Lead 1 (-), AVF (-) deviasi kanan
ekstrim
4. Zona Transisi
: V5
5. Morfologi
- P Wave
:- Interval PR
: 3 kk = 0,12 sec
- Q Wave
: Q patologis (-)
- Kompleks QRS: 4 kk = 0,2 sec melebar Lead I, Lead
II, lead III, AVR, AVL, AVF, V3, V4, V5, V6
- Segmen ST
: ST elevasi (-), ST depresi (-)
- T Wave
: T inverted (+) AVR, AVL
T tall (-)
Interpretation : RVH, RBBB

EKG Interpretation
1.
2.
3.

Irama
Frekuensi
Axis

: Sinus
: 1500/18 kk = 83
: Lead 1 (-), AVf (-) Deviasi kanan
ekstrim
4. Zona Transisi
: V4
5. Morfologi
- P Wave
: P mitral (-), P pulmonal (-)
- Interval PR
: 5kk = 0,2 sec
- Q Wave
: Q patologis (-)
- Kompleks QRS: 4 kk = 0,16 sec melebar LI, LII, LIII,
AVL, AVF
- Segmen ST
: ST depresi (+) V2, V3, V4 ST elevasi
(-)
- T Wave
: T inverted (+) V1, V2, V3, V4
T tall (-)
Interpretation : RVH, RBBB

RO THORAX

Impressions
Cor :
Cardiomegali ( Suspek LVH, LAH)
Pulmo:
Tampak infiltrat paru di lobus bawah paru kanan

USG

Impressions
- Cystitis
- Moderate hidronefrosis kanan kiri dan hidroureter
proksimal kanan kiri
- Ekogenitas kortek kedua ginjal meningkat, dengan
batas kortikomeduler kabur cenderung gambaran
proses kronis pada kedua ginjal

Echo

Impressions
Global normokinetik, fungsi LV+RV sistolik baik, LVH konsentrik, disfungsi LV diastolik

Data Abnormality
Anamnesis :

Dyspneu (1)
Weakness (2)
Nausea (3)
Vomitus (4)
Hypertension
history (5)
Heart disease
history (6)
DM history (7)
Kidney disease
history (8)
Hemodialisa history
(9)

Physic Examination
:
Conjungtiva
anemic (+/+) (10)
Cardiomegali (11)
Hipertensi (12)
Tachypneu (13)

Lab :
Anemia (14)
Leukocytosis (15)
Azotemia (16)
Hyponatremia (17)
Hypercalemia (18)
Hyperchlorida (19)

GDS :
Hyperglikemia (20)
X-Ray :
Cor kardiomegali (21)
(suspek LVH, LAH)
USG :
Cystitis (22)
Hidronefrosis &
hidroureter (23)
ECG :
RVH (24)
RBBB (25)
Hipercalemia (26)
Bradikardia with
Total AV Block (27)
Echo :
Global normokinetik
(28)

Problem List
1. CHF (1, 2, 6, 11, 13, 21, 24, 25, 28)
2. CKD (3, 4, 8, 9, 14, 16, 17, 18, 19)
3. HIPERTENSI GRADE II (3, 4, 5, 12)
4. DM TYPE II (7, 20)
5. ANEMIA (10, 14)
6. HIPERKALEMIA (18, 26)
7. CYSTITIS (15, 22)
8. HIDRONEFROSIS & HIDROURETER (23)
9. BRADIKARDIA WITH TOTAL AV BLOK (27)

CHF
Ass
Anatomi diagnosis (LVH, RVH)
Etiology Diagnosis (HHD, IHD)
IP.Dx
BNP/Pro-BNP
IP.Tx
Non Farmacology
Bed rest
of sit down position
O2 2-3 L/minutes
Diet Low salt
Farmacology
Captopril 3 x 6,25 mg
Furocemid 2x 20 mg iv
Laktulosa 1 x 1

Ip.Mx
General Condition
Vital sign
ECG
Ip.Ex
Explain about the disease
Maintain weight
Reduce salt intake and
Avoid alcohol and cigarette
Consumption drug regularly
Routine check of blood
pressure.
High fiber diet

CKD
Ass

Emergency treatment of CKD


- Hiperkalemi
-Asidosis Metabolik
- hipertensi
IP.Dx
BGA
Phospat in blood
IP.Tx

Non Farmakology :
Diet low protein 0,6-0,8g/kgBB/day
Diet low salt 1 gram
Diet fluid 500cc + how much urine
mL/day Farmakology
:
CaCO3 3 x 500mg to prevent
hiperfosfatemia
bicnat 3 x 500mg to prevent acidosis
metabolic
Technical Therapy : Hemodialisa when
creatinin clearence tolerance decrese until
<15

IP.Mx
Balance of fluid,
Diuresis,
Vital sign
Awareness,
Chemical blood tests
Electrolyte
IP.Ex
Expalin
Explain
Explain
intake

about
about
about

disease
hemodialisa
nutrition and water

HIPERTENSION GRADE II
Ass
Maligna Hypertension
Benigna Hypertension
IP.Dx
Funduskopi
Micral test
IP.Tx

Non Farmacology
Diet low salt

Farmacology
Captopril 2 x 6,25 mg
Amlodipin 1x10 mg

IP.Mx
Vital sign
ECG
IP.Ex
Reduce salt intake, avoid
alcohol and cigarette
Mild Exercise at least 30 minute
everyday
Consumption drug regularly
Routine check of blood
pressure.

DM TYPE II
Ass
Makroangiopati (peny jantung
koroner, penyakit arteri perifer,
penyakit cerebrovasculer)
Mikroangiopati (retinopati diabetik,
nefropati diabetik, neuropati
diabetik)
IP.Dx

Funduscopy
Micral test
Ct-scan cranium
Angiography

IP.Tx
Non Farmacology
Reducing carbs and glucose
consumption
Low glucose intake dietary
Farmacology

IP.Mx
Daily blood glucose test, HBA1c,
GDPP, GDP
IP.Ex
Maintain weight
Avoid drink and eat too much carbs
and glucose
Consumption drug regularly
Routine check of blood glucose

ANEMIA
Ass
Normokrom normositer,
Hipokrom mikrositer
IP.Dx
MCH
MCV
MCHC
Retikulosit tes
Fe/TIBC
IP.Tx
SF 300 mg 3x1 tab
Vit c 500 mg 1x 1 tab

IP.Mx
Blood test (, Hb, Ht, Leukosit,
Trombosit)
IP.Ex

:-

HIPERKALEMIA
Ass
Emergency treatment
IP.Dx

:-

IP.Tx
Hemodialisa
IP.Mx
General condition
Electrolyte
IP.Ex
Bedrest

CYSTITIS
Ass
Acute
Cronic
IP.Dx
BNO or BNO IVP
IP.Tx
Farmacology
Cefixime 3 x 500
IP.Mx

:-

IP.Ex
Penggunaan antiseptik setelah
BAK
Hygiene genitalia eksterna

HIDRONEFROSIS & HIDROURETER


Ass
IP.Dx
IP.Tx
IP.Mx
IP.Ex

BRADIKARDI & TOTAL AV BLOCK


Ass
IP.Dx
IP.Tx
IP.Mx
IP.Ex