Department of Internal Medicine

Faculty of Medicine Sultan Agung Islamic University

2017

Case Based Discusion

Dwi Ayu Lestari
30101206609
Advisor :
dr. H. M. SAUGI ABDUH, Sp.PD., KKV, FINASIM
Patient Identity
Name : Mrs. T

Age : 48 years old

Gender : Female

Religion : Moslem

Job : housewife

Address : Trimulyo 01/01, Genuk, Semarang

MR number : 01014052

Room : ICU Bed 11

Entry date : September, 29th, 2017

Date out : October 9th, 2017

History taking

Main Problem
Dyspneu

History of present illness

Patient came to Emergency Unit of Sultan Agung Hospital
with dyspneu since 7 days ago. For the first time, dyspneu
occured while the patient was doing mild activity. Then
dyspneu appeared without activity since 1 day ago. Patient
also complained that both of hands and legs were swelled
since 10 days ago before coming to hospital.
HISTORY OF ILLNESS
HISTORY OF PREVIOUS ILLNESS
SOSIO-ECONOMIC HISTORY :
History of Same Illness (+)
Hospital cost certified by
Hypertension history (-)
BPJS-NPBI
DM history (-)
Asthma history (-)
Alergy history (-) FAMILYS HISTORY OF DISEASE
Uric Acid (-) Hypertension history (+)

DM history (-)

Heart Disease History (-)

Asthma history (-)

SISTEMIC ANAMNESIS
Chief Complains : Dyspneu

Onset : 7 days ago

Location : Chest

Chronology : She Complained that 7days ago about her

dyspneu. with mild activity And worsten 1 day ago.

Quality and Quantity : patients feel dyspneu when mild activity

and worsent without activity

Modification factor : Better when she sit down.

Comorbid complains : swelling extremities.

GENERAL STATUS
BMI (Body Mass Indeks)
weight : 50 BMI= 50/(1.57 x1.57) = 20,3
High : 157
Intepretation :
Normoweight

General : weakness, dyspneu

Awareness : Stupor
Vital Sign
Blood Pressure : 80/55 mmHg
Heart rate : 140 x/minute
Breath Frequency : 28 x/minute
Temp : 36,2oC Intepretation :
Unconsciousness, hipotensi,
takikardi, takipneu
 Head : Mesocephal, alopesia (-)

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

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

Ears : Normal Shape, discharge (-/-)

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

Mouth : Cyanosis (-), dry lips (+),

Neck : Trakhea deviation (-), Lymph Hypertropy (-), Increasing

JVP 5 3cm

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

Intepretation : Oedem of both
extremity, Increasing JVP
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 (-), Stem costae angle < 900, enlargement of
fremitus D=S ICS (-), Stem fremitus D=S

Percution Sonor Sonor

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

Palpation : Ictus cordis is palpable at ICS VI 2 cm lateral from linea

midclavicularis sinistra, thrill (+) with four finger, 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 parasternal 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 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
EXTREMITY EXAMINATION
Ekstremitas Superior Inferior

Oedema +/+ +/+

Cold -/- +/+

Jaundice -/- -/-

Intepretation : Oedema of
both extremity
Laboratorium Examination
 30/09/2017 01/10/2017 03/10/2017 04/10/2017 09/10/2017

Uric Acid 16.5 mg/dL - - -

(H)
Ureum 130 mg/dL (H) 163 mg/dL(H) 209 mg/dL (H) 218 mg/dl (H) 296 mg/dl (H)

Blood 3.64 mg/dL 4.30 mg/dL(H) 4,89 mg/dL (H) 5,29 mg/dl (H) 5,30 mg/dl (H)
Creatinin (H)

Haemoglobin 14,8 g/dl - 12,2 g/dl 12,3 g/dl 15,3 g/dl

Hematocrit 45,0 % - 35,0 % 36,4 % 46,5 %(H)

Leukosit 11,01 ribu/uL - 8,75 ribu/uL 10,93 ribu/uL 3,34 ribu/uL (L)
(H)
Trombosit 204 ribu/uL - 136 ribu/uL (L) 119 ribu/uL(L) 450 ribu/uL (H)

HbSAg - - - Non Reaktif

Natrium 134,2 mmol/L - - 127,6 mmol/L 130,7 mmol/L
(L) (L) (L)
Kalium 5,09 mmol/L - - 5,25 mmol/L (H) 6,60 mmol/L (H)
(H)
Chloride 94,8 mmol/L - - 95,9 mmol/L 96,4 mmol/L
(L)
Calcium 8,7 mmol/L (L)

Cholesterol 132 mg/dl - - -

trigliserid 91 mg/dl - - -

HDL 21 mg/dL (L) - - -

LDL 75 mg/dl - - -

SGOT 44 U/I (H) - - -

SGPT 23 U/I - -

Albumin 3,37 g/dL (L) -

Fe 153 ug/L -

TIBC 342 ug/L -

Interpretation

Uric Acid (hiperuricemia)

Ureum, Creatinin (Azotemia)
Trombocyte (Trombositopenia)
leucosyte (Leukocytosis)
Natrium ( Hiponatremia)
Kalium (hiperkalemia)
Chloride
SGOT
Albumin (Hipoalbuminemia)
Calcium (Hipocalcemia)
SERIAL ECG
29/9/2017 , 9.10 pm
 Interpretation
Rhytm : Atrial
Regularitas : Iregular
Frekuensi : 140 x/menit
Axis : lead 1 = -; AvF = + RAD
Zona Transisi : V2
Gelombang P : fibrillation
Interval PR : cannot be evaluated
Komplek QRS : 0,08 detik (normal)
Gelombang Q : normal
Segmen ST : normal
Gelombang T : T inverted pada lead III, aVR,aVF,V2

Kesan :Atrial Fibrillation, RAD, ischemic anteroinferior

1/10/2017, 5.45 am
 Interpretation
Rhytm : Atrial
Regularitas : Iregular
Frekuensi : 70 x/menit
Axis : lead 1 = -; AvF = + RAD
Zona Transisi : V2
Gelombang P : fibrillation
Interval PR : cannot be evaluated
Komplek QRS : 0,08 detik (normal)
Gelombang Q : normal
Segmen ST : normal
Gelombang T : T inverted pada lead V2, V3

Kesan :Atrial Fibrillation, RAD, ischemic anterior

2/10/2017
 Interpretation
Rhytm : Atrial
Regularitas : Iregular
Frekuensi : 83 x/menit
Axis : lead 1 = -; AvF = + RAD
Zona Transisi : V2
Gelombang P : fibrillation
Interval PR : cannot be evaluated
Komplek QRS : 0,08 detik (normal)
Gelombang Q : normal
Segmen ST : normal
Gelombang T : T inverted pada lead III, V1, V2

Kesan :Atrial Fibrillation, RAD ischemic anteroinferior

3/10/2017
 Interpretation
Rhytm : Atrial
Regularitas : Iregular
Frekuensi : 60 x/menit
Axis : lead 1 = - ; AvF = + RAD
Zona Transisi : V3
Gelombang P : fibrillation
Interval PR : cannot be evaluated
Komplek QRS : 0,08 detik (normal)
Gelombang Q : normal
Segmen ST : normal
Gelombang T : T inverted pada lead III, VI,V2

Kesan :Atrial Fibrillation, ischemic anteroinferior

4/10/2017
 Interpretation
Rhytm : Atrial
Regularitas : Iregular
Frekuensi : 60 x/menit
Axis : lead 1 = -; AvF = + RAD
Zona Transisi : V3
Gelombang P : fibrillation
Interval PR : cannot be evaluated
Komplek QRS : 0,08 detik (normal)
Gelombang Q : normal
Segmen ST : normal
Gelombang T : T inverted pada lead III, V2, V3

Kesan :Atrial Fibrillation, RAD , ischemic anteroinferior

5/10/2017
 Interpretation
Rhytm : Atrial
Regularitas : Iregular
Frekuensi : 60 x/menit
Axis : lead 1 = -; AvF = + RAD
Zona Transisi : V2
Gelombang P : fibrillation
Interval PR : cannot be evaluated
Komplek QRS : 0,08 detik (normal)
Gelombang Q : normal
Segmen ST : normal
Gelombang T : T inverted pada lead III, Vi, V2, V3

Kesan :Atrial Fibrillation, RAD, ischemic anteroinferior

6/10/2017
 Interpretation
Rhytm : Atrial
Regularitas : Iregular
Frekuensi : 54 x/menit
Axis : lead 1 = -; AvF = + RAD
Zona Transisi : V3
Gelombang P : fibirallation
Interval PR : cannot be evaluated
Komplek QRS : 0,08 detik (normal)
Gelombang Q : normal
Segmen ST : normal
Gelombang T : T inverted pada lead III, V2, V3

Kesan :Atrial Fibrillation, RAD, ischemic anteroinferior, bradikardi

7/10/2017
 Interpretation
Rhytm : Atrial
Regularitas : Iregular
Frekuensi : 42x/menit
Axis : lead 1 = -; AvF = + RAD
Zona Transisi : V2
Gelombang P : fibrillation
Interval PR : cannot be evaluated
Komplek QRS : 0,08 detik (normal)
Gelombang Q : normal
Segmen ST : normal
Gelombang T : T inverted pada lead III, ,aVF, Vi, V2

Kesan :Atrial Fibrillation, RAD, ischemic antero inferior, bradikardi

 ECG SERIAL RESULT
ECG RESULT
DATE ST T Enlarge INTERPRETATION
Axis
depression inverted ment
29/9/2017 isoelektris III, aVR, LI (-), N AF, RAD, Ischemic
AVF AVF (+) anteroinferior
1/10/2017 isoelektris V2, V3 LI (-), N AF, RAD, ischemic
AVF (+) anterior
2/0/2017 isoelektris III, V1, V2 LI (-), AVF N AF, RAD, ischemic
(+) anteroinferior
3/10/2017 isoelektris III, V1, V2 LI (-), N AF, RAD, ischemic
AVF (+) anteroinferior
 ECG SERIAL RESULT
ECG RESULT
DATE ST T Enlarge INTERPRETATION
Axis
depression inverted ment
4/10/2017 isoelektris III, V2, V3 LI (-), N AF, RAD, ischemic
AVF (+) anteroinferior
5/10/2017 isoelektris III, V1, V2, LI (-), N AF, RAD, ischemic
V3 AVF (+) anteroinferior
6/0/2017 isoelektris III, V2, V3 LI (-), AVF N AF, RAD, ischemic
(+) anteroinferior
7/10/2017 isoelektris III, aVF, LI (-), N AF, RAD, ischemic
V1, V2 AVF (+) anteroinferior
Chest X-Ray
X-Foto Thorax
COR = Apeks ke caudolateral,
pinggang jantung menghilang,
tampak double contour, conus
pulmonalis menonjol, batas kanan
bergeser ke lateral
Pulmo = Corakan bronkovaskuler
tak meningkat, tak tampak
gambaran infiltrat
Diafragma dan sinus kostofrenikus
tak tampak kelainan.

Kesan =
COR = Cardiomegaly (Suspek LV, LA,
RA)
Saat ini tak tampak gambaran edema
pulmonum
 ECG :

Abnormal Data 12. AF,

13. Ischemic anteroinferior

Physical Chest X-Ray:

Examination 14. Cardiomegaly
5. Takipneu
Lab
6. Hipotensi 15. Uric Acid (hiperuricemia)
7. takikardi 16. Ureum (Azotemia)
History Taking
17. Creatinin
1. Orthopneu, 8. Increasing JVP 18. Natrium (hiponatremia)
5 3cm 19. Trombocyte
2. coughing
20. leucosyte
3. Swelling 9. Cardiomegaly 21. Kalium (hiperkalemia)
10. Oedema of 22. Chloride
extremities.
23. SGOT
both extremities 24. Albumin (Hipoalbuminemia)
11. Ronki (+) 25. Calcium (Hipocalcemia)
 Additional Data
Date DC/BC/D
30/9/2017 BC Com = +105/15jam
1/10/2017 DC = 500cc/24jam , D = 0,3cc/KgBB/jam, BC com= -156,0/39
jam
2/10/17 DC = 80cc/24 jam, D = 0,05 cc/KgBB/jam, BC com=
+26,79/61 jam
3/10/2017 DC = 130cc/24jam, D = 0,09 cc/KgBB/jam, BC com =
+611,19/35 jam
4/10/2017 DC = 310 cc/24 jam, D = 0,21 cc/KgBB/jam, BC = -183
5/10/2017 DC = 110cc/24jam, D = 0,07 cc/KgBB/jam, BC = +253,2
6/10/2017 DC = 30cc/24jam, D = 0,02/KgBB/jam, BC Com =
+987,29/157 jam
7/10/2017 DC = 230/24jam, D = 0,06/KgBB/jam,

8/10/2017 DC = 740cc/24jam, D = 0,5/KgBB/jam,

 Problem List

CHF
Cardiogenic Shock 1. Orthopneu
AF
3.Swelling extremities
Unconciossneus, 8. Increasing JVP
6. Hipotensi 9. Cardiomegaly from PF
12. ECG AF
10. Oedema of both extremities
7. Takikardi
14. Chest X-Ray Cardiomegaly

IHD
CKD
18. Ischemic anteroinferior from ECG
16. Ureum : 296 mg/dl (H)
17 creatinin : 5, 30mg/dl
Problem List

Hiperkalemi Hipoalbuminemia Hipocalcemia

21. Kalium : 6,60 24. Albumin : 3,37
mmol/L g/dL 25. Calcium : 8,7 mmol/L

Hiponatremia Hiperuricemia
18. Natrium : 130,7 mmol/L 15. Uric acid : 16,5 mg/dl
 Cardiogenic Shock

Ass : emergency condition to prevent cardiac arrest

IP Dx : ECG, BGA
Ip Tx :
Airway
Breathing = NRM 10 lpm
Circulation =
Injeksi Dobutamin 1x1 amp (250mg/mL)
Injeksi NE 5x1 amp ( 4mg/4mL)
RL 15tpm
Ip Mx : Awarness, Vital Sign, ECG, Diuresis,
MAP = (Sistole + 2Diastole) : 3
= ( 80 + 110) : 3 = 63,3 mmHg (<65 mmHg)

BP = CO x SVR (Tahanan Pembuluh Sistemik)

= (SV x HR)
 Congestive heart failure

Ass :
Anatomi : LVH, LAH, RAH
Fungsional : NYHA IV
Etiologi : IHD, AF

IP Dx : - BNP ( 35 pg/mL) dan Pro-BNP ( 125 pg/mL) , Echocardiography,

angiography coroner
Ip Tx :
o Injeksi Furosemide 2x1 amp (20mg/2mL)
o Injeksi Digoxin 1x1 amp (0,5mg/2mL)
o Bisoprolol 2,5mg po 1x1
o Lactulosa syr 1x1
 AF (Atrial Fibrilation)

Ass : Stroke, Bleeding

IP Dx : skor CHA2 DS2 -VASc and HAS-BLED
IP Tx : Injeksi Digoxin 1x1 amp (0,5mg/2mL)

IPMx : ECG serial, Vital Sign, side effect drug.

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 (bila nyeri dada)

Ip.Mx : ECG

Ip.Ex :

Reducing Emotional stress

Reducing eat that food contain high cholesterol

Avoid smoke cigarette

 Assassement : emergency condition to prevent
CKD metabolic acidosis, seizure, hyperkalemia, bleeding,
crisis hypertention, over hidration, infection.
IP Dx : BGA, 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

IP Mx
Vital Sign, GFRLFG, uremic sign, general state, awareness,
fluid balance
 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
 Laju Filtrasi Glomerulus (LFG) :
140 ()
=
72 ( )

= (140- 48)x50 / 72x5,29 = 12,077 x 0,85

= 10,265 Chronic Kidney
Disease Grade V
Hiperurisemia

Assassemen : excretion IP Mx
disorder Uric Acid, Pain
IP Dx : - IP Ex
Avoid Organ meats high in
IP Tx : purine contains ( liver,
kidney, seafood)
Non Pharmacologic
Avoid sweetened soda
Diet low protein and beverage
purine food
Do Excercise
Pharmacologic Stay well hydrated
Allopurinol 100 mg 0-0-1
Hiperkalemi
Assassemen : Cardiotoxic, Metabolic acidosis
IP Dx : BGA
IP Tx : Hemodialysis, dietary restriction
IP Mx
kalium status, General state, Awareness, ECG, Vital Sign,

IP Ex
Explain about disease
Explain about treatment and side effect
 Hiponatremia
Assassemen :
- Increase amount fluid intake
- Inability to suppress the ADH secretion sirosis hepatis, CHF
- Hemodilusi ex causa CKD ( decreasing urine excretion)

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
 Hipoalbuminuria
Assassemen : increase excretion
IP Dx : -
IP Tx :
koreksi albumin 0,8 x 50 x (3,5-3,37) = 5,2 gram
Albumin intake 20 % in 50 cc = 10 gr

IP Mx
Albumin status, General state, Awareness, ECG, Vital Sign,

IP Ex
Explain about disease
Explain about treatment and side effect
 Hipocalcemia
Assassemen :
Vitamin D deficiency low fat intake
disturbed of vitamin D metabolism

IP Dx : -
IP Tx :
Corr Ca (mg/dL) = Total serum Ca [ 0.8 (4 Albumin) ]
= 9,7 [0,8 x ( 4- 3,37)] = 9,196 mg/dL
10 mL calcium gluconate 10 % in NaCl 0,9 % 1 ampul = 10 mL

IP Mx
calcium status, General state, Awareness, ECG, Vital Sign,

IP Ex
Explain about disease
Explain about treatment and side effect