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CBD

CASE BASE DISCUSSION

MUHAMMAD SUKRON
30.10120.6682 Advisor :
dr. H. M. SAUGI ABDUH, Sp.PD., KKV, FINASIM

Department of Internal Medicine


Medical School of Sultan Agung Islamic University
2016
Name : Mrs. S
Age : 49 years old
Gender : Female
Religion : Moslem
Job : Housewife
Address : Kudu RT 05/05, Genuk Semarang
MR number : 129.22.44
Room : Baitul Izzah 1 410.4
Entry date : August 10th, 2016
Date out : August 14th, 2016
HISTORY TAKING

Main Dyspneu
Problem

Patient came into policlinic department of Islamic


History
of Hospital of Sultan Agung Semarang Complained
Present about her abnormal breathing (dyspneu). Its started 3
Illness days ago when do activity. Patient usually wake up in
the midnight when he felt dyspneu. The patient had
dispnue since more than one month ago. Patients also
complained weak and loss of appetite. Patient need
more pillow when slept to decrease her dispneu.
HISTORY OF ILLNESS
HISTORY OF PREVIOUS ILLNESS
SOSIO-ECONOMIC HISTORY :
Hypertension history (+)
Hospital cost certified by
DM history (-)
JKN NON PBI
Asthma history (-)
Alergy history (-)
Dhiarrea history (+)

FAMILYS HISTORY OF DISEASE

Hypertension history (+)

DM history (-)

Asthma history (-)

Alergy history (-)


SISTEMIC ANAMNESIS
Main Complains : Abnormal breathing (dyspneu)
Onset : 3 days ago
Location : Chest, feel hard to breath.
Chronology : She Complain that 3 days ago he feel hard to
breath when daily activity. The breath feel more
better when she take a rest
Quality and Quantity : Patient feel hard to breath everytime and
disturbing activities.
Modification factor : He felt better when break the activity and sit
back relax.
Comorbid complains : Weak, headache, and cough
PHYSICAL EXAMINATION
General : dyspneu (+),weakness

Skin : itching (-), redness (-),jaundice (-), pale (-), slick (-),
Head : headache (+)

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

Jafroy dign (+), rossenbacht (+), mobius sign (-), fon grave sign (+/+),
stelwagh sign (-)
Ears : hearing loss (-), ring (-), discharge (-)

Nose : nosebleed (-), discharge (-), nostril breath (-)

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

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


Neck : enlargement of the gland/thyroid (+/+)
Chest : cough (+), sputum (-), blood (-)

Cardiac : chest pain (-), palpitations (-)


Digestive : abdominal pain (-), nausea (-), vomiting (-)
GENERAL STATUS
BMI (Body Mass Indeks)
weight : 48kg BMI=48: 1,50 = 21,3
High : 150cm
Intepretation :
NormoWeight

General : Dyspneu
Awareness : Fully aware / Compos Mentis
Vital Sign :
Blood Pressure : 170/85 mmHg
Heart rate : 80 x/minute
Breath Frequency : 28 x/minute
Temp : 36,5oC Intepretation :
Hypertension stage II
GENERAL STATUS
Head : Mesocephal, alopesia (-)
Eyes : Anemic Conjuntiva(-/-),Icteric sclera(-/-), exoftalmus (+/+)
Nose : symmetric, secret (-), Nostril Breath (-)
Ears : Normal Shape, discharge (-/-)
Esophagus : Hyperemic (-), pain devour (-)
Mouth : Cyanosis (-), dry lips (-),
Neck: Trakhea deviation (-), Lymph Hypertropy (-), enlargement
thyroid glands (+/+)
Extremity : Oedem of lower extremity / upper extremity (-) / (-)

plakat eritematous with soft skuama (-)


Intepretation : Enlargement thyroid glands,
exoftalmus
LUNG EXAMINATION
INSPEKSI ANTERIOR POSTERIOR

Static RR : 28x/min, Hyper pigment (-), spider nevi RR : 28x/min, Hyper pigment
(-), atrophy Pectoral Muscle (-), Hemithoraks (-),spider nevi (-), Hemithoraks D=S,
D=S, ICS Normal, Diameter AP < LL ICS Normal, Diameter AP < LL

Dynamic Up and down of hemitoraks D=S, Up and down of hemitoraks D=S,


abdominothorakal breathing, (-), muscle abdominothorakal breathing (-), muscle
retraction of breathing (-), retraction of breathing(-),
retraction ICS (-) retraction ICS (-)

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

Percution Sonor Sonor

Auskultation Vesicular (-), Whezzing (-), Ronchi (-) Vesicular (-), Whezzing (-), Ronchi (-)

Intepretation : Normal
CARDIAC EXAMINATION
Inspection : Ictus cordis isnt seen.

Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-),


sternal lift (-).

Percussion : dull sound


Upper borderline of heart : ICS II left sternal line
Waist of heart : ICS III left parastern line
Lower right borderline of heart : ICS V right sternal line
Lower left borderline of heart : ICS VI, 2 cm lateral from left
mid clavcle line
...CONT

Auscultation
Aortal valve : S1 & S2 standard, additional sound (-)

Pulmonary valve : S1 & S2 standard, additional sound (-)

Tricuspid valve : S1 & S2 standard, additional sound (-)

Mitral valve : S1 & S2 standard, additional sound (-)

Intepretation : Cardiomegaly
ABDOMEN EXAMINATION
Inspection : symetric, sycatric(-), striae(-),enlargement of vena (-),
caputmedusa (-), plakat eritematous with soft skuama (-)
Auscultation : peristaltic (-)
Palpation :
Superfisial : tight (-), mass (-)
Deep : abdominal pain (+), liver, kidney, and spleen werent
palpable, Murphys sign (-)
Percussion : tympani, side of deaf (-), shifting dullness (-)
Liver : deaf(+), right liver span 11 cm, left liver span 6 cm
Spleen :Throbe space percussion (+) tympani

Intepretation : Normal
EXTREMITIES EXAMINATION

Ekstremitas Superior Inferior

Oedema -/- -/-

Cold -/- -/-

Jaundice -/- -/-


LAB. EXAMINATION
10/8/2016 Hematology 12/8/2016 Hormon
Hb 11,8 g/dl TSHs <0,05
Ht 35,1% Free T4 >100

Leukosit 5,47 ribu/uL 10/8/2016 Kimia


Trombosit 170 ribu/Ul GDS 138

27/10/2015 Kimia

Natrium 141.3 mmol/L


Intepretation : Kalium 4,30 mmol/L
Hyperthyroid Chloride 100 mmol/L
X-RAY THORAX

Intepretation :
1. Cor : CTR > 50%
2. Pulmo : corakan bronkovascular
normal,tak tampak bercak pada
kedua paru
Diafragma dan sinus kostofrenikus baik
KESAN:
Cor : CARDIOMEGALI
Pulmo : Tidak tampak kelainan
ECG (11/08/2016)
Ritme : Atrial
REGULARITAS : Irregular, Irreguler
FREKUENSI : 90x/minutes (normal respons)
GELOMBANG P : abnormal, P wave disappear/small
PR INTERVAL : unidentified
QRS COMPLEX : 2 x 0,04 = 0.08 (Normal)
ST SEGMEN : 4 x 0,04 = 0,16 (Normal), isoelektris
GELOMBANG T : Normal
ZONA TRANSISI : V3
AXIS : Lead I (+) dan aVF (+) : NAD

Intepretation : Atrial Fibrilation


ECHO
Dimensi ruang jantung : Membesar di LA

Dinding LV : Tidak menebal


Wall motion : Global Normokinetik

Katup jantung : Normal


Fungsi RV sistolik baik : TAPSE 1,7 mm
Fungsi LV Diastolik gangguan relaksasi
Fungsi LV sistolik Baik EF 64%

Kesan:
Global Normocinetic
Normal of sistolic RV & LV function,
Mild disfunction of diastolic
Dilatation of LA
Abnormal Data
History Taking
1. Dyspneu, 2.
dispneu
deffort, 3. Ro Thoraks :
orthopneu 10.Cardiomegaly
4.weak
5.Headache ECG : Lab
6. dhiarrea 11. Atrial Fibrilation Hematology
14.Hyperthyroid
Physical
ECHO
Examination
12. Mild disfunctin of
7.Enlargement of
diastolic
Thyroid glands
13. Dilatation of LA
8.Exoftalmus
9.High blood
preasure : 170/85
PROBLEM LIST
1 2 3
CHF NYHA 2 HYPERTENSION HYPERTHYROID
(1, 2,3,4,5,9,12) STAGE II ( 6,7,10,15)
( 7)

4
ATRIAL
FIBRILATION
( 6,7,10)
1. CHF NYHA 2
Ass: Etiologi : Thyroid Heart Disease

Anatomi :-

Fungsional : NYHA II

IP Dx : BNP and Pro-BNP

IP Tx :

Non Pharmacology Pharmacology


Low Fat Intake Infus RL 30 tpm
Low Salt intake Laktulosa syr 1 x 1
Reduce activity Asam Folat 1x1
High fiber Diet Propanolol 10mg 2x1
Ip. Mx : Vital sign, ECG, ECHO
Ip. EX :
Bed Rest/Restriction of physical activity
Sodium & Fluid `restriction
Reducing Emotional stress
Sit position or a half sleep position
2. 2nd Grade Hypertension
Ass :

- Risk factor cardiovascular (HT) : DM, dislipidemia, obesitas

- Hyperthyroid

Ip Dx : LDL, HDL, trigliserid, total cholesterol, waist circumference, uric acid

Ip Tx :

Non Pharmacology :

Low salt intake

Do exercise

Pharmacology :

Captopril 2 x 12.5 mg

Amlodipin 1 x 5 mg
Ip. Mx : Vital Sign

Ip.Ex :

Diet low salt

Consumption vegetable, fruit

Routine consumption drugs


American Society of Hypertension and the International Society of Hypertension 2013
3. GRAVES DISEASE
Ass : -

IP Dx : -

IP Tx : Non pharmacology

Pharmacology - High calori (food, suplemen)


-Tirosol 5 mg 2x1 - High protein
-Propanolol 10 mg 2x1 - Do exercise

Ip. Mx : Lab (TSHs, T4), sign and symtom


Ip. EX :
- routine consume medicine
Propanolol (B-Blocker)
4. ATRIAL FIBRILASI
Ass: thrombo-embolism

IP Dx : -

IP Tx :

Pharmacology : Warfarin 5 mg/ day

Non pharmacology : Diet low fat

Ip. Mx : EKG 12 lead, PT, INR


Ip. EX : explain about his disease to his family
CHA2DS2-VASc Score
CHF YES
HIPERTENSION YES
AGE >65 TH NO
DM NO
STROKE NO
VASCULAR DISEASE NO
MALE NO

CHA2DS2-VASc SCORE 2
RISK CATEGORY MODERATE RISK
ANTITHROMBOTIC RECOMENDATION ORAL ANTICOAGULATION
HAS-BLED Score
HIPERTENSION (SBP >160 MMHG) YES
ABNORMAL RENAL FUNCTION NO
ABNORMAL LIVER FUNCTION NO
AGE > 65 NO
STROKE NO
PRIOR MAJOR BLEEDING NO
LABILE INR NO
TAKING DRUGS PREDISPOSING BLEEDING YES
ALCOHOL USE NO

HAS-BLED SCORE 2
RISK CATEGORY MODERATE
ESTIMATED MAJOR BLEEDING 4,9-19,6%
TERIMAKASIH