CASE BASED DISCUSSION

54 yo, male with

dyspneu

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

Arranged by :
Denaya Tika Reskia
30101206605
 I. PATIENT IDENTITY
Name: Mr. W
Age : 54 yo
Sex : Male
Religion : Moeslem
Job : -
Numb of Medical Record : 01194936
Address : Jl. Batursari 1, sawah besar gayamsari, semarang
Room Care : Baitul Izzah 1
Date in : 21 July 2017
Date out : 26 July 2017
Status Care : PBI
 HISTORY TAKING
Main problem : dyspneu

Onset : since a week ago

Chronology : dyspneu was felt for 1 years, and becoming
more heavy since a week ago
Location : in the chest
Quality : becoming more heavy, paroxismal nocturnal
dyspneu
Quantity : it wasnt reduce by take a rest
Modification factor : heavy activity, orthopneu
Additional symptoms : swollen at lower extremity
 HISTORY TAKING (cont)
History of previous disease
Asthma history (-)
Hypertension history (+)
DM history (+)
Heart disease history (-)
Smoking (-)
Maag (-)
Allergy (-)
Drug-induced hyperthermia (-)

History of family disease

Asthma history (-)
Hypertension history (+)
DM history (+)

Socio-economic history

Hospital cost is covered by JKN-PBI

 II. PHYSICAL EXAMINATION
II.1. Vital Sign
VITAL SIGN

BP HR RR SPO2
Temperature
162/92 mmHg 117x/minute 35x/minute 99%
37,7 C
II.2. General Status
GENERAL WEAKNESS

AWARENESS Composmentis

HEAD Mesocephal, alopesia (-)

EYES Anemic Conjuntiva (-/-), Icteric sclera (-/-)

NOSES Symmetric, secret (-), Nostril Breath (-)

EARS Normal Shape, Discharge (-/-)

ESOPHAGUS Hyperemic (-), Pain devour (-)

MOUTH Cyanosis (-), Dry lips (-), Stomatitis angularis (-)

NECK Trakhea deviation (-), Lymph Hypertropy (-),

Increaing jugular vein pressure (+)

EXTREMITY Oedem of lower extremity (+)

II. 3. Chest (Lung Examination)
ANTERIOR POSTERIOR

INSPECTION mass (-) mass (-)

inflamation (-) inflamation (-)
hemithorax movement D=S hemithorax movement D=S
SIC (Normal) SIC (Normal)

PALPATION pain (-) pain (-)

tumor (-) tumor (-)
stem fremitus (D=S) stem fremitus (D=S)

PERCUSSION dextra : sonor dextra : sonor

sinistra : sonor sinistra : sonor
Dullnes in basal (-) Dullnes in basal (-)
AUSCULTATION Basic pulmonary sound : Basic pulmonary sound :
broncovesicular broncovesicular

Additional : Additional :
Ronchi symmetrical in basal (-/-) Ronchi symmetrical in basal (-/-)
II. 4. (Heart Examination)

INSPECTION Ictus cordis isnt seen.

PALPATION Ictus cordis is palpate at SIC VI linea mid clavicula sinistra

thrill (-)
pulsus epigastrium (+), pulsus para-sternal (+), sternal lift (+).

PERCUSSION - Upper borderline of heart : SIC II linea sternalis sinistra

- Waist of heart : SIC II linea para sternalis sinistra
- Lower right borderline of heart : SIC IV lineasternalis dextra
- Lower left borderline of heart : SIC VI linea axillaris anterior sinistra

AUSCULTATION - Aorta valve : S1 & S2 standart, additional sound (-), AI < A2

- Pulmonal valve : S1 & S2 standart, additional sound (-), P1 < P2
- Trikuspidal valve : S1 & S2 standart, additional sound (-), T1 > T2
- Mitral valve : S1 & S2 standart, additional sound (-), M1 > M2
II. 5. Abdomen Examination

INSPECTION sycatric(-)
striae(+),
enlargement of vena (-)
caput medusa (-)
Ascites (-)

PALPATION peristaltic (N)

vascular bruit (-),
intestinal bruit (-)

PERCUSSION - Hepar : deaf (+), liver span dextra11 cm, liver span sinistra 6 cm
- Lien : troube space percussion (-)
- Kidney : costovertebra pain percusiion (-)

AUSCULTATION - Superfisial : abdominal pain (-)

- Deeper : abdominal pain (-), hepar & lien arent palpable
II. 6. Extremity
EXTREMITY SUPERIOR INFERIOR
(D/S) (D/S)
OEDEM -/- +/+

COLD EXTREMITY -/- -/-

PHYSIOLOGICAL +/+ +/+

REFLEX
ICTERIC -/- -/-

BW : 60 kg
Height : 160 cm
BMI : 23,43 kg/m2 Normoweight
III. ADVANCE EXAMINATION

HEMAT
OLGY

ECG

CHEST
X-RAY
 III. 1. Hematology
21/7/2017
HEMATOLOGY RESULT NORMAL VALUE

DARAH RUTIN 1

Hemoglobin 9,9 g/dl 13,2 17,3 g/dl

Hematokrit 29,9 % 33 45 %

Leukosit 18,86 ribu/uL 3,8 10,6 ribu/uL

Trombosit 309 ribu/uL 150 440 ribu/uL

Golongan darah/ Rh B/positif

KIMIA

Ureum 121 mg/dl 10 50 mg/dl

Creatinin 3,24 mg/dl 0.6 1,1 mg/dl

Albumin Globulin
Albumin 2,97 g/dl 3,4 4,8 g/dl

SGOT 32 U/l 0 50 U/l

SGPT 48 U/l 0 50 U/l

Na, K, Cl
Natrium 134,3 mmol/L 135 147 mmol/L

Kalium 4,38 mmol/L 3,5 5 mmol/L

Chloride 104,6 mmol/L 95 105 mmol/L

Calcium 9,3 mmol/L 8,8 10,8 mmol/L

Magnesium 1,9 mg/dL 1,6 2,4 mg/dL

III. 2. ECG
INTERPRETATION
Sinus tachycardia
III. 3. Chest X-Ray
21/7/2017

Cor :
Apex to the laterocaudal side
Pulmo :
Corakan vaskuler isnt increase
There is no infiltrat illustration
There are no abnormality of
diaphragm and costophrenicus
sinus
KESAN :
CARDIOMEGALY
(SUSPECT LV)
THERE ISNT ILFILTRAT
ILLUSTRATION IN PULMO
 IV. DATA ABNORMALITY

HISTORY PHYSICAL ADVANCE

TAKING EXAMINATION EXAMINATION

1. Dispneu 4. Hypertention 10. Haemoglobin (L)

2. Oedema at lower 5. Tachycardia 11. Hematokrit (L)
extremity 6. Hypertermia 12. Leukocyte (H)
3. History of 7. Increasing JVP 13. Azotemia
Hypertention & DM 8. Oedem at lower 14. Hypoalbumin
(+) extremity 15. Hyponatremia
9. Cardiomegaly 16. Cardiomegaly
V. PROBLEM LIST
CHF

CKD

ANEMIA
PROBLEM LIST

HYPERTENTION

OBS FEBRIS

HYPOALBUMIN

HYPONATREMIA

AZOTEMIA
 VI. INITIAL PLAN
CHF

IP Dx:
Echocardiography, Framingham Diagnostic Criteria, NHYHA Functional Classification,
AHA Stages of HF, Evidence based BNP & NT pro-BNP cutoff value

IP Rx:
NP : Oxygen,
P : Diuretics, vasodilators, inotropic agents, anticoagulants, beta blockers, and
digoxin
Furosemide 2x2A
Captopril 6,25 2x1
Digoxin 2x0,125 mg
Lactosa`1x2c

IP Mx:
ECG, Vital Sign, Complete blood count (CBC)

IP Ex:
Dietary sodium and fluid restriction, physical activity as appropriate, and attention to
weight gain
 VI. INITIAL PLAN (cont)
CKD
IP Dx:

GFR = (140 age) x BB (kg)

72 x creatinin serum (mg/dl)

GFR 22,11 mg,dL (stage IV) Severely reduced renal function.

IP Rx:

IP Mx:
Complete blood count (CBC)
Serum albumin levels

IP Ex:
Source : the johns hopkins internal medicine (p.276)
 VI. INITIAL PLAN (cont)
ANEMIA

IP Dx:
Blood morphology

IP Rx:
Sulfas ferrosus 3x200mg
Vit C 1x1

IP Mx:
Clinical features
Hb, Ht

IP Ex:
High intake food contain Fe
Source : the johns hopkins internal medicine (p.393)
 VI. INITIAL PLAN (cont)
HYPERTENTION

IP Dx:
JNC 7/8

IP Rx:
irbesartan 300 mg 1x1
IP Mx:
Blood pressure

IP Ex:
change lifestyle, exercise, diet low sodium, food
containing low fat, consuming healthy food
Source : the johns hopkins internal medicine (p.14)
 VI. INITIAL PLAN (cont)
OBS FEBRIS

IP Dx:
infection
urinalisis, kultur urine, DR, FPA, PIV, sistouretrografi, usg, CT- scan

IP Rx:
Fluoroquinolon (ciprofloxacin)
Acute uncomplicated: Immediate-release, 250 mg PO q12hr for 3 days;
extended-release, 500 mg PO q24hr for 3 days
Mild/moderate: 250 mg PO q12hr or 200 mg IV q12hr for 7-14 days
(medscape)
Paracetamol : 2 x 500 mg

IP Mx:
clinical manifestation, temperature, leucocyte count,

IP Ex:
Healthy diet
urethra hygiene
 VI. INITIAL PLAN (cont)
HYPOALBUMIN

IP Dx: -

IP Rx:
Albumin correction (Albumin target Alb actual) x BB x 0.8 =
(gr)
Alb corr : (3,5 2, 97) x 60 x 0,8 = 0,43 x 48 = 25,44 gram

Albumin gram (iv) 25 gram

po Inbumin 2x1

IP Mx:
albumin count

IP Ex:
high intake protein
 VI. INITIAL PLAN (cont)
HYPONATREMI

Ass :
Actual [Na+] = 134,3 mmol/L
Mild = [Na+] = 125135 mEq/L
IP Dx:

IP Rx:
Na correction [Na+] = 0,5 x BW(kg) x (target [Na+]
konsentrasi [Na+] awal)
= 0,5 x 60 x (135 134,3 ) 30 x 0,7 = 21
Natrium 1 flash
IP Mx:
Natrium count

IP Ex:
Source : the johns hopkins internal medicine (p.254)
 VI. INITIAL PLAN (cont)
AZOTEMIA

IP Dx:
Goals increase renal perfusion and to maintain urine output.
GFR
IP Rx:
Diuretic DOC : furosemide (20-40 mg IV/IM once).
It inhibits sodium chloride reabsorption in the thick ascending
limb of the loop of Henle. (medscape)

IP Mx:
Vitas sign, GFR, ureum creatinin count, urin analysis, fluid balance

IP Ex:
Source : the johns hopkins internal medicine (p.260)
VII. INITIAL PLAN
IP Dx

IP Rx

IP Mx

IP Ex
Thank You