Department of Internal Medicine

Faculty of Medicine Sultan Agung Islamic University

2019

Case Based Discusion

Afifah Nur Aliyyah
30101307116
Advisor :
dr. H. M. SAUGI ABDUH, Sp.PD., KKV, FINASIM
Patient’s Identity
Name : Mr. AH

Age : 77 years old

Gender : Female

Religion : Moslem

Job :-

Address : Ds Tangkis RT 03/03 Guntur Demak

MR number : 01132348

Room : Baitul Izzah 1

Entry date : September, 19th, 2019

Date out : September, 26th, 2019

History taking

Main Problem
• Dyspneu

History of present illness

• Patient came to Emergency Unit of Sultan Agung Hospital
with dyspneu since 2 hours ago before coming to hospital.
Dyspneu occured while the patient was doing mild activity.
Dyspneu appeared suddenly and continuously. Patient not
felt better when he took a rest and sit down. Patient also
complained weak, cough, and swelling extremity
HISTORY OF ILLNESS
HISTORY OF PREVIOUS ILLNESS
SOSIO-ECONOMIC HISTORY :
History of Same Illness (+)
Hospital cost certified by
Cardiac disease history (+)
“BPJS-NPBI”
Hypertension history (+)
DM history (-)
Asthma history (-) FAMILY’S HISTORY OF DISEASE
Allergy history (-) Hypertension history (-)
Drug allergy (-) DM history (-)
Uric Acid (-)
Cardiac disease history (-)

Allergy history (-)

Asthma history (-)

SISTEMIC ANAMNESIS
Chief Complains : Dyspneu

Onset : 2 hours ago

Location : Chest

Chronology : He Complained that 2 hours ago he feel hard to

breath when mild activity
 Quality and Quantity : Dyspneu appeared suddenly and
continuously.
 Modification factor : Patient not felt better when he took a rest
and sit down

Comorbid complains : weak, cough, swelling extremities.

GENERAL STATUS
BMI (Body Mass Indeks)
weight : 58 BMI= 58/(1.56 x 1.56) = 24,16 kg/m2
height : 156
Intepretation :
Normoweight

General : weakness, dyspneu

Awareness : fully aware / compos mentis
Vital Sign
• Blood Pressure : 110/70 mmHg
• Heart rate : 70 x/minute
• Breath Frequency : 28 x/minute
• Temp : 36,0oC
Intepretation :
hipotensi, takipneu
 Head : Mesocephalic, alopecia (-)

 Eyes : Anemic Conjuntiva(-/-),Icteric sclera(-/-)

 Nose : symmetric, secret (-), Nostril Breath (-)

 Ears : Normal Shape, discharge (-/-)

 Esophagus : Hyperemic (-), pain devour (-)

 Mouth : Cyanosis (-), dry lips (-), snoring (-)

 Neck : Trachea deviation (-), Lymph Hypertropy (-), swelling (-),

Increasing JVP 5 ± 3cm

 Extremity : Oedem of lower extremity / upper extremity (+) / (-)

Intepretation : Increasing JVP,
oedem of lower extremity
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 (-),
retraction of breathing (-), muscle retraction of breathing(-),
retraction ICS (-), epigastric retraction (-) retraction ICS (-)

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

Percution Sonor Sonor

Auskultation Vesicular (+), Whezzing (-), Ronchi (+) Vesicular (+), Whezzing (-), Intepretation :
Ronchi (-) Takipneu,
oedem pulmo
CARDIAC EXAMINATION
Inspection : Ictus cordis isnt seen.

Palpation : Ictus cordis is palpable at ICS VI 3 cm medial from linea midclavicularis

sinistra, 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 parasternal line
 Lower right borderline of heart : ICS V right sternal line
 Lower left borderline of heart : ICS VI, 2 cm lateral from left mid clavicle
line

Intepretation : Cardiomegaly
 ...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 : Normal
ABDOMEN EXAMINATION
Inspection : symetric, sycatric(-), striae(-),enlargement of vena (-),
caputmedusa (-).
Auscultation : peristaltic (+)
Palpation :
• Superfisial : tight (-), mass (-), epigastrial pain (-)
• Deep : abdominal pain (-), liver, kidney, and spleen weren’t
palpable, Murphy’s 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
EXTREMITY EXAMINATION
Ekstremitas Superior Inferior
• Pitting
Oedema -/- +/+
• Cold -/- -/-
• Jaundice -/- -/-

Intepretation : pitting oedem

LABORATORIUM EXAMINATION
PEMERIKSAAN HASIL NILAI RUJUKAN SATUAN PEMERIKSAAN HASIL NILAI RUJUKAN SATUAN

HEMATOLOGY KIMIA

Hemoglobin 10.0 (L) 13.2 - 17.3 g/dl Gula Darah 129 (H) 75 - 110 mg/dl
Sewaktu
Hematokrit 29.1 (L) 33 - 45 % Ureum 154 (H) 10 - 50 mg/dl

Leukosit 7.37 3.8 – 10.6 ribu/uL Creatinin Darah 5.39 (H) 0.7 – 1.3 mg/dl

Trombosit 191 150 - 440 ribu/uL Natrium 130.5 (L) 135 - 147 mmol/L

Golongan B / Positif - Kalium 5.90 (H) 3.5 - 5 mmol/L

Darah/Rh
Chloride 103.7 95 - 105 mmol/L

Interpretation: Anemia, Hiperglikemi, Azotemia, Hiponatremi, Hiperkalemi

Chest X-Ray

X-Foto Thorax
 COR = apeks ke laterokaudal.
Elongasi arcus aorta
 Pulmo = carakan vaskuler tak
meningkat. Tak tampak gambaran
infiltrat
Diafragma sisi kanan tampak
scalloping.
Sinus kostofrenikus kanan kiri lancip

Interpretation =
Cardiomegaly (LV)
Elongasi arcus aorta
Pulmo tak tampak gambaran infiltrat
ECG 19/9/2019 , 10.10 pm
 Interpretation
 Rhytm : Sinus
 Regularity : Regular
 Frequency : 70 x/menit
 Axis : lead 1 = +; AvF = -  LAD
 Transition zone : V2
 P wave : 0,08 s (normal)
 PR Interval : 0,20 s (normal)
 QRS Interval : 0,08 s (normal)
 Pathologic Q wave : + di lead II, III, aVF
 ST Segment : elevated ST (-), depressed ST (-)
 T wave : Inverted T di lead V4, V5, V6

Interpretation : OMI inferior, ischemic lateral

 Echo Summary
Dimensi ruang jantung
: Tidak membesar

ECHO Dinding LV :
Menebal di PW
Wall Motion :
Global Hipokinetik
Katup jantung : AR
Mild TR Mild MR
Mild
Fungsi LV Sistolik
Menurun EF 38%
Fungsi RV Sistolik Baik
TAPSE 17 mm
Fungsi LV Diastolik baik
E/A > 1

Interpretation:
 Global Hipokinetik
 Decrease of
sistolic LV function
 Fungsi RV Sistolik
baik
 Hipertropi PW
 AR Mild TR Mild MR
Mid
Abnormal Data
Chest X-Ray:

Physical ECG : 18. Cardiomegaly

12. OMI inferior 19. Elongation of
Examination
13. Ischemic lateral aorta
History Taking 6. Takipneu
Lab
1. Dyspneu 7. Hipotensi
ECHO : 20. Anemia
2. Orthopneu 8. Increasing JVP 14. Global 21. Hiperglikemi
3. Weakness 5 ± 3cm Hipokinetik 22. ↑ Ureum
15. Decrease of (Azotemia)
4. Coughing 9. Oedem pulmo sistolic LV 23. ↑ Creatinin
5. Swelling 10. function 24. ↓ Natrium
16. Hipertropi PW (hiponatremia)
extremities Cardiomegaly 17. AR Mild TR 25. ↑ Kalium
11. Oedema of Mild MR Mid (hiperkalemia)

both extremities
Problem List

CHF
1. Orthopneu IHD
2. Swelling extremities Azotemia 1. Ischemic inferior from
3. Increasing JVP
1. Ureum : 296 mg/dl (H) ECG
4. Oedem Pulmo
2. creatinin : 5, 30mg/dl 2. Decrease of sistolic LV
5. Cardiomegaly from PF
function
6. Oedema of both extremities
7. Chest X-Ray Cardiomegaly

Hiperglikemi Hiperkalemi Hiponatremia

GDS : 129 mg/dl Kalium : 6,60 mmol/L Natrium : 130,7 mmol/L
 Congestive heart failure

 Ass :
 Anatomi : LVH
 Fungsional : NYHA III
 Etiologi : IHD, HHD
 IP Dx : BNP (≥ 35 pg/mL) dan Pro-BNP (≥ 125 pg/mL), angiography coroner
 IP Tx :
 Pharmacology

oInfus RL 20 tpm
oInjeksi Furosemide 2x1 amp (20mg/2mL)
oBisoprolol 2,5mg po 1x1
oARB
  Non Pharmacology

oLow Fat intake

oLow Salt intake
oReduce activity
oHigh fiber diet

 IP Mx : vital sign, ECG, awareness

 IP Ex :
 Bed Rest/Restriction of physical activity
 Sodium & Fluid restriction
 Reducing Emotional stress
 Sit position or a half sleep position
Ischemic Heart Disease
Ass: Etiologi : Unstabel Angina

Non ST Elevasi Myocard Infarction ( NSTEAMI)

IP Dx : Mioglobin, CKMB, Troponin I, Troponin T, Profil Lipid

IP Tx :

 Non Pharmacology

 Low Fat Intake

 High Fiber diet

 Pharmacology

Aspilet 1 x 80 mg (maintenance)

CPG 1 x 75 mg (maintenance)

Isosorbidinitrat 5 mg k/p (if chest pain)

Ip.Mx : ECG

Ip.Ex :

 Reducing Emotional stress

 Reducing eat that food contain high cholesterol

 Avoid smoke cigarette

 Hiponatremia
 Assassemen : -

 IP Dx : -
 IP Tx :
Natrium correction  0,6 x 50 x (140 - 134,2) = 174 mEq/L

NaCl 0,9 % 1 flabot  1 flabot NaCl 0,9 % : Na 154 meq/L ; Cl 154 meq/L

 IP Mx
 Natrium status post correction, General state, Awareness, ECG, Vital Sign,

IP Ex
 Explain about disease
 Explain about treatment and side effect
Hiperkalemi
 Assassemen :-
 IP Dx : -
 IP Tx : Hemodialysis, dietary restriction
Farmakologi : sodium bicarbonat  to exchange K+ extra vaskular to
intravaskular
, ca glukonas, insulin combine with dextrose 10%.  to prevent aritmia
Restin  to binding K+ perifer
 IP Mx
 kalium status, General state, Awareness, ECG, Vital Sign,

IP Ex
 Explain about disease
 Explain about treatment and side effect
Hiperglikemi
 Assassemen : DM & non DM
 IP Dx : GDP, GD2PP, TTGO
 IP Tx :
 Non Pharmacology :
 Lifestyle management
 Medical nutrition theraphy
 Exercise

 IP Mx : Blood glucose
 IP Ex :
 Explain to patient about the condition, and complication that may occur
 Controlling dietary habits
 Reduce glucose intake
 Exercise
  Assassement : CKD
Azotemia  IP Dx : USG Kidney
 IP Tx :
 Non pharmacologic :
 Limitation of protein intake (0.6-0.8/kgBB/day),
 Calorie Intake 30-35 kkal/kgBB/day
 Dialysis
 Pharmacologic :
 CaCO3 3x1
 Asam folat
 Bicarbonat (prevent metabolic asidosis)

 IP Mx
 Vital Sign,GFR, uremic sign, general state, awareness, fluid
balance, ureum creatinin level
 IP Ex
 Explain to the patient about the disease
 Explain about dialysis
 Take medicine regularly
 Explain side effect of medication
 Explain about proper daily intake, including type of diet and food
 Routine Control of Blood Pressure
TEORI
CHF
The Power of PowerPoint | thepopp.com 44
The Power of PowerPoint | thepopp.com 45
The Power of PowerPoint | thepopp.com 46
HIPONATREMI
HIPERKALEMI
 Summary

UA NSTEMI AMI

Simptom Angineus 20 mnt/> Berat > 30 mnt

Sign + + + & > berat

EKG ST elevasi/depresi ST depresi Hiperakut T

T: pos tinggi & menetap > dlm & ST elevasi
simetris /neg dalam lama Q patologis
T : neg dalam

Marker CKMB ( - ) CKMB positif CKMB ( + )

Tropinin + / - Troponin - / + Troponin + / -
HIPERGLIKEMI
CKD
 Laju Filtrasi Glomerulus (LFG) :
140−𝑈𝑚𝑢𝑟 𝑥𝐵𝐵 (𝑘𝑔)
= 𝑚𝑔
72𝑥𝑠𝑒𝑟𝑢𝑚 𝑘𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛( )
𝑑𝐿

= (140- 75)x58 / 72x5,39 = 3770 x 388

= 9,71
 Kriteria CKD (terjadi lebih dari 3 bulan)
Penanda kerusakan ginjal (1 - Albuminuria (AER ≥ 30mg/24
atau lebih) jam; ACR ≥ 30mg/g (≥3
mg/mmol)
- Abnormalitas sedimen urin
- Abnormalitas elektrolit atau
lainnya yang berkaitan
dengan gangguan tubulus
- Abnormalitas struktur yang
dideteksi dari radiologi
- Riwayat transplantasi ginjal
Penurunan laju filtrasi GFR < 60 ml/menit/1,73 m2
glomerulus (GFR)
 Old Classification of CKD as Defined by Kidney Disease
83 Outcomes Quality Initiative (KDOQI) Modified and Endorsed
by KDIGO
Stage Description Classification Classification
by Severity by Treatment
1 Kidney damage with GFR ≥ 90
normal or increased GFR
2 Kidney damage with GFR of 60-89 T if kidney
mild decrease in GFR transplant

3 Moderate decrease in GFR GFR of 30-59 recipient

4 Severe decrease in GFR GFR of 15-29 D if dialysis

5 Kidney failure GFR < 15 D if dialysis

Note: GFR is given in mL/min/1.732 m²

KDIGO, Kidney
National Kidney Foundation. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Disease: Increasing
Evaluation, Classification, and Stratification. Am J Kidney Dis 2002;39(suppl 1):S1-S266 Global Outcomes
Rencana Tatalaksana Penyakit Ginjal Kronik sesuai
dengan derajatnya (Sudoyo, 2014)

Derajat LFG (mlmnt/1.73 m2) Rencana tatalaksana

1 ≥ 90 Terapi penyakit dasar, kondisi komorbid,
evaluasi perburukan (progression) fungsi
ginjal, memperkecil risiko kardiovaskuler

2 60-89 Menghambat perburukan (progression)

fungsi ginjal

3 30-59 Evaluasi dan terapi komplikasi

4 15-29 Persiapan untuk terapi pengganti ginjal
5 <15 Terapi pengganti ginjal
 Kidney Disease: Improving Global Outcomes
(KDIGO) CKD Work Group. Kidney Int Suppls.
2013;3:1-150.
 Indikasi hemodialisa
Hemodialisis segera atau
emergency
• Uremia ( BUN >150mg/dL)
• Oliguria (urin < 200ml/12jam)
• Anuria (urin < 50ml/ 12jam)
• Asidosis berat (pH < 7.1)
• Hiperkalemia
• Ensefalopati uremikum
• Neuropati Uremikum
• Hipertermia
• Disnatremia (Natrium > 160
atau < 115 mmol/L)
Hemodialisis kronik, yaitu
hemodialisis yang dilakukan
seumur hidup
• Dimulai apabila dijumpai
salah satu gejala yaitu :
• a. LFG < 15ml/menit,
tergantung gejala klinis
penderita
• b. Malnutrisi atau hilangnya
massa otot
• c. Gejala uremia antara lain
anoreksia, mual muntah,
lethargy
• d. Hipertensi yang susah
dikontrol
• e. Kelebihan cairan
 KOMPLIKASI
89
90 NUTRISI PADA PASIEN CKD :
KOMPOSISI MAKRONUTRIEN DAN MINERAL

Adapted from DASH (dietary approaches to stop hypertension) diet.

*Adjust so total calories from protein, fat, and carbohydrate are 100%. Emphasize such whole-food sources as
fresh vegetables, whole grains, nuts, legumes, low-fat or nonfat dairy products, canola oil, olive oil, cold-water
fish, and poultry.

*(CKD Stages 1-4)

NKF KDOQI. Am J Kidney Dis. 2007;49(suppl 2):S1-
S179.