Keadaan umum : Sakit sedang Kesadaran : Compos mentis

26-28 x/menit, cepat dangkal

Tekanan darah : 110/60 mmHg Pernafasan :
SO2 96% O2 3lpm
HR = N : 116x/menit Suhu : 38.6
Konjungtiva anemis (+), sub-konjungtival hemorrhage (-), sklera ikterik (-), Pernafasan Cuping Hidung (+), Sianosis Peri
Kepala Oral (-)
JVP 5+ 2 cm H2O, Hepatojugular reflux (+), KGB tak teraba membesar. Trakea di tengah. Retraksi Sternokleidomastoid
Leher (-)
Thoraks Bentuk dan gerak simetris, batas sonor dull setinggi ICS V kanan, peranjakan sdn , Retraksi intercostal (+)
Cor Ictus cordis tidak tampak, teraba di intercostal space V Linea Mid Clavicularis Sinistra, kuat angkat (-), thrill (-), batas
kanan 1 cm lateral Linea Sternalis Dextra, batas atas intercostal space III, batas kiri ICS V Linea Mid Clavicularis
Sinistra. Bunyi jantung S1, S2 (A2,P2) normal, S3 (-), S4 (-), PSM (+) grade 3/6 di LLSB, carvallo sign (+), muffled sound
(-)
Pulmo
Hemithorax kanan Hingga ICS II: Vocal Fremitus turun, Sonor, Vesicular Breathing Sound turun, Vocal Resonance sdn
Ronkhi -, Wheezing –
Hemithorax kanan ICS III kebawah: Vocal Fremitus normal, Sonor, Vesicular Breathing Sound normal, Vocal Resonance
sdn Ronkhi -, Wheezing –
Hemithorax Kiri :
Vocal Fremitus normal, Sonor, Vesicular Breathing Sound normal, Vocal Resonance sdn Ronkhi -, Wheezing –

Abdomen
datar, lembut, BU (+) normal, nyeri tekan (-), Lien tidak teraba, Ruang Traube kosong, Pekak Samping (-)

Ekstremitas Akral hangat +/+, cap refill <2” , clubbing -/-, sianosis -/-, edema pitting +/+, Janeway lesion (-), Osler node(-), splinter
hemorrhage (-), KGB aksillaris tidak teraba, petechiae (+) a/r ekstremitas atas
 EKG RSHS (22/06/19)

• Irama sinus, QRS axis normal, QRS rate 114x/menit, gelombang P 0.08 s, 0.1 mv, PR
interval 0.16 s, Q patologis (-), durasi QRS 0.08 s, ST segmen isoelektris, T inversi (+) V1-
3, R/S di V1 < 1, SV1/2+RV5/6 <35 mm, RaVL+SV3<28, S V deep + S di V4 < 28 mm
• Diagnosis EKG : Sinus takikardi, nonspecific t wave inversion
 LABORATORIUM
Darah Rutin : Nilai Normal Diff. Count Nilai Normal
Hemoglobin 6.3 g/dL 13.5-17,5 g/dL Basofil 0% 0-1 %
 
Hematokrit 19.3 % 40-52 % Eosinofil 0% 1-6 %
Lekosit 11690 mm3 4.400- Batang 1% 3-5 %
11.300/mm3
Eritrosit 2.32 juta/µL 3,6-5,8juta/µL Segmen 85% 40-70 %
Trombosit 159.000/mm3 150.000- Limfosit 8% 30-45 %
450.000/mm3
MCV 83.2 fl 80-100 fl Monosit 6% 2-10 %
MCH 27.2 pg 26-34 pg  anti HIV Non reaktif 
MCHC 32.6 % 32-36%  HbsAg Non reaktif 
Anti HCV > 11
Kimia Darah   AGD  
Ureum 24.5 mg/dL 15-50mg/dL pH 7.438 7.35-7.45
Kreatinin 0.57 mg/dL 0,7-1.2 mg/dL PCO2 24.8 35.0-45.0 mmHg
eGFR 130 > 90ml/min PO2 94.6 80-105 mmHg
mL/min/1.73m2
GDS 115 mg/dL < 200 mg/dL HCO3 16.9 22-26 mmol/L
Natrium 132 mEq/L 135-145 mEq/L TCO2 17.7 23.05-27.35 mmol/L
Kalium 4.0 mEq/L 3,6-5,5 mEq/L BE -5.8 (-2)-(+2) mmol/L
Kalsium 4.48 mg/dl 4.5-5.6 mg/dl SaO2 95 95-100
Magnesium 2.1 mg/dl 1.8-2.4 mg/dl      
 
Urinalisis        
Warna Kuning Kuning Eritrosit >50 0-3
Kejernihan Keruh   Leukosit 10-19 1-5
Berat Jenis 1.015 1.001-1.035 Epitel 0-1 0-1
pH 5.0 5.0-8.0 Bakteri Bakteri Negatif
coccus
Nitrit - Negatif Kristal - Negatif
Protein - Negatif Silinder - Negatif
Glukosa - Negatif      
Keton - Negatif Morfologi Darah tepi
Urobilinogen +1 Negatif Eritrosit Hipokrom anisopoikilosis (target
cell, ovalosit, cigar shape)
mikrosit
Bilirubin - Negatif Leukosit Jumlah meningkat,
hipersegmentasi (+), granula
toksik (+)
Leukosit Esterase +1 Negatif Trombosit Jumlah cukup, tersebar
Eritrosit +3 Negatif      
          
Urinalisis        
Warna Kuning Kuning Eritrosit >50 0-3
Kejernihan Keruh   Leukosit 10-19 1-5
Berat Jenis 1.015 1.001-1.035 Epitel 0-1 0-1
pH 5.0 5.0-8.0 Bakteri Bakteri Negatif
coccus
Nitrit - Negatif Kristal - Negatif
Protein - Negatif Silinder - Negatif
Glukosa - Negatif      
Keton - Negatif Morfologi Darah tepi
Urobilinogen +1 Negatif Eritrosit Hipokrom anisopoikilosis (target
cell, ovalosit, cigar shape)
mikrosit
Bilirubin - Negatif Leukosit Jumlah meningkat,
hipersegmentasi (+), granula
toksik (+)
Leukosit Esterase +1 Negatif Trombosit Jumlah cukup, tersebar
Eritrosit +3 Negatif      
          
LABORATORIUM
KULTUR
ISOLATE 1 Staphylococus aureus Sensitif terhadap
-Ampicilin/ sulbactam
-cefoxitin screen
-Ceftriaxon
-Gentamycin
-amoxilin/clavulanate
-piperacillin
-S cephalotin
-cefazolin
-cefuroxime
-cefoperazone
-cefotaxime
Ceftazidim
Cefepime
Ciprofloxacin
Levofloxacin
Moxifloxaci
Co-trimoxazole
Tygecycline
Vancomycin
Clindamycin
Erythromycin
Ertapenem
meropenem
KULTUR
ISOLATE 1 Staphylococus aureus Sensitif terhadap
-Ampicilin/ sulbactam
-cefoxitin screen
-Ceftriaxon
-Gentamycin
-amoxilin/clavulanate
-piperacillin
-S cephalotin
-cefazolin
-cefuroxime
-cefoperazone
-cefotaxime
Ceftazidim
Cefepime
Ciprofloxacin
Levofloxacin
Moxifloxaci
Co-trimoxazole
Tygecycline
Vancomycin
Clindamycin
Erythromycin
Ertapenem
meropenem
THORAX FOTO (22/7/19)
• CTR 52%, segmen aorta tidak melebar,
segmen pulmonal tidak menonjol, pinggang
jantung mendatar, apeks tertanam,
kranialisasi (-), sudut costophrenicus kiri
tertutup perselubungan, sudut
costophrenicus kanan tajam. corakan
bronkovaskuler normal, tampak
perselubungan opak inhomogen di lapang
paru bilateral atas sampai bawah. Tampak
bayangan lusen avascular dengan pleural
line (+) di hemitoraks lateral tengah sampai
bawah kanan.Tampak rongga lusen multiple
berdinding tebal di lapang tengah paru
kanan
• Kesan :
• Kardiomegali tanpa bendungan paru
dd/ posisi
• Suspek TB paru
• Pneumothorax dextra
• Rongga lusen multiple berdinding
tebal di lapang tengah paru kanan
suspek tuberculoma
echocardiography

• Normal all chambers, LVEF 60% biplane with

normokinetik at rest.
• Severe TR ( uncoaptation, flail anterior and posterior
leaflet, hepatic vein reversal +, vegetation 1.6x 1.1 cm
attach to all tricuspid leaflet)
• normal diastolic function, normal RV contractility, mild
pericardial effusion (0.3cm-0.8cm)
Echocardiografi evaluasi
Duke criteria

• Pathological criteria
• Kriteria mayor : 2 (Kultur darah positif terhadap
kuman IE, imaging (echocardiography ) positif
terhadap IE (vegetasi)
• Kriteria minor : 2 (Adanya kelainan jantung
predisposisi terhadap IE/Injected drug user (IDU),
Demam >38°C, fenomena vaskular, fenomena
imunologis, bukti mikrobiologis yang tidak memenuhi
kriteria mayor)
 DIAGNOSIS KERJA

• Definitive Infective Endocarditis

• Pneumothorax dextra spontan ec suspek pecah Bleb dd
septic pulmonary emboli
• Suspect TB paru kasus baru
• Anemia Inflamasi
• malnutrisi
 TATA LAKSANA
• Non farmakologis: Farmakologis:
• Bed Rest, Vancomycin 2 x 675 mg IV
• Intake Cairan 1500 cc/ 24 jam
Gentamycin 135 mg IV
• Diet Lunak 1404 kkal/hari, Protein 1
gr/kgBB/hari (180kcal), KH:L (60: 40 ) 735 : Furosemide 1x40 mg IV
489 kalori
Paracetamol 500 mg po prn bila suhu >
• Kultur dan Tes sensitivitas darah (sampel 38,50C
darah diambil 3x di tempat berbeda dengan
interval pengambilan darah pertama dan  
terakhir lebih dari 1 jam)
• Monitor TNRS IO, edukasi mengenai Terapi TS IPD
penyakit dan tatalaksana
Callos 3x1

Rencana Pemeriksaan
Echocardiography evaluasi
Konfirmsi hasil kultur
Perika TCM dan BTA sputum 3x
R/ transfusi PRC
 Follow Up
25/6/19 26/6/19 27/6/19
S   Sesak berkurang, demam sesak Sesak-
(-)
O : Sakit sedang, compos mentis Sakit sedang, compos mentis Sakit sedang, compos mentis
  : Tensi : 130/80 Tensi : 130/80 Tensi : 130/80
  HR =N : 100x/menit,REIC HR =N : 100x/menit,REIC HR =N : 100x/menit,REIC
  R: 24 x/m R: 24 x/m R: 24 x/m
  S: 36.6 C S: 36.6 C S: 36.6 C
  SaO2 98% O2 3 lpm SaO2 98% O2 3 lpm SaO2 98% O2 3 lpm
JVP 5+2 cm H2O JVP 5+2 cm H2O JVP 5+2 cm H2O
Ronkhi -/- Ronkhi -/- Ronkhi -/-
Edema +/+ minimal Edema +/+ minimal Edema +/+ minimal

Kultur : staphylococcus aureus Kultur : staphylococcus aureus Kultur : staphylococcus aureus

Lab (24/6) Lab: Lab:

Hb 6.6/ht 19.9/eri Hb 9/ht 26.6 eri 3.11/leukosit Hb 7.6/ht 23/eri 2.67/leukosit
2.37/leukosit 9050/trombosit 201000/DC 10410/trombosit 216000/DC
11070/trombosit 222000/DC 0/0/0/83/12/5 /Na 138 K 3 ca 0/0/1/82/12/5 / SGOT
0/0/0/84/11/5 / K 3.9/Ca 4.3 mg 1.8 29/SGPT 55/bil total 0.930/bil
4.72/HbsAg kromatografi non I: 900cc/24 jam direk 0.707/bil indirek 0.223
reaktif/anti HIV non O: 1000cc/24 jam I: 1200cc/24 jam
reaktif/Anti HCV >11 B:-100cc/24 jam O: 1400cc/24 jam
I: 1000cc/24 jam B:-200cc/24 jam
O: 1300cc/24 jam
B:-300cc/24 jam
A : Hemodinamik Stabil Hemodinamik Stabil Hemodinamik Stabil
Failure (-) Failure (-) Failure (-)
Hepatitis C kronis

P : Terapi lanjutkan
 28/6/19 29/6/19 30/6/19
S   Sesak berkurang, demam (-) sesak Sesak-
O : Sakit sedang, compos mentis Sakit sedang, compos mentis Sakit sedang, compos mentis
  : Tensi : 130/80 Tensi : 130/80 Tensi : 120/70
  HR =N : 100x/menit,REIC HR =N : 90x/menit,REIC HR =N : 90x/menit,REIC
  R: 24 x/m R: 24 x/m R: 24 x/m
  S: 36.6 C S: 36.6 C S: 36.6 C
  SaO2 98% O2 3 lpm SaO2 98% O2 3 lpm SaO2 98% O2 3 lpm
JVP 5+2 cm H2O JVP 5+2 cm H2O JVP 5+2 cm H2O
Ronkhi -/- Ronkhi -/- Ronkhi -/-
Edema -/- Edema -/- Edema -/-
Kultur : staphylococcus aureus
Kultur : staphylococcus aureus Kultur : staphylococcus aureus
Lab:
Lab (24/6) Hb 7.6/ht 23/eri 2.67/leukosit Lab:
Hb 7.6/ht 23/eri 2.67/leukosit 10410/trombosit 216000/DC Hb 7.6/ht 23/eri 2.67/leukosit
10410/trombosit 216000/DC 0/0/1/82/12/5 / SGOT 29/SGPT 10410/trombosit 216000/DC
0/0/1/82/12/5 / SGOT 29/SGPT 55/bil total 0.930/bil direk 0/0/1/82/12/5 / SGOT 29/SGPT
55/bil total 0.930/bil direk 0.707/bil indirek 0.223 55/bil total 0.930/bil direk
0.707/bil indirek 0.223 I: 1200cc/24 jam 0.707/bil indirek 0.223
I: 1200cc/24 jam O: 1400cc/24 jam I: 1200cc/24 jam
O: 1400cc/24 jam B:-200cc/24 jam O: 1400cc/24 jam
B:-200cc/24 jam B:-200cc/24 jam
A : Hemodinamik Stabil Hemodinamik Stabil Hemodinamik Stabil
Failure (-) Failure (-) Failure (-)
Hepatitis C kronis Hepatitis C kronis Hepatitis C kronis

P : Tranfusi PRC 1 kantung Cefotaxim 3x2gr iv Cefotaxim 3x2 gr iv

Tranfusi PRC 1 kantung
 1/7/19 2/7/19 3/7/19
S   Sesak berkurang, demam (-) sesak Sesak-
O : Sakit sedang, compos mentis Sakit sedang, compos mentis Sakit sedang, compos mentis
  : Tensi : 120/80 Tensi : 130/80 Tensi : 120/70
  HR =N : 96x/menit,REIC HR =N : 90x/menit,REIC HR =N : 90x/menit,REIC
  R: 24 x/m R: 22x/m R: 22 x/m
  S: 36.6 C S: 36.6 C S: 36.6 C
  SaO2 98% O2 3 lpm SaO2 98% O2 3 lpm SaO2 98% O2 3 lpm
JVP 5+2 cm H2O JVP 5+2 cm H2O JVP 5+2 cm H2O
Ronkhi -/- Ronkhi -/- Ronkhi -/-
Edema -/- Edema -/- Edema -/-
Kultur : staphylococcus aureus
Kultur : staphylococcus aureus Kultur : staphylococcus aureus

Lab (1/7/19) I: 1200cc/24 jam TCM : tidak ditemukan DNA

Hb 9,9/ht 29,9/eri 3,49/leukosit O: 1300cc/24 jam mycobacterium tuberculosis
9090/trombosit227000/DC B:-100cc/24 jam
0/0/0/83/12/5 / albumin 1.9 I: 1500cc/24 jam
I: 1200cc/24 jam O: 1300cc/24 jam
O: 1400cc/24 jam B:+200cc/24 jam
B:-200cc/24 jam

A : Hemodinamik Stabil Hemodinamik Stabil Hemodinamik Stabil

Failure (-) Failure (-) Failure (-)
Hepatitis C kronis Hepatitis C kronis Hepatitis C kronis

P : Cefotaxim 3x2 gr iv Cefotaxim 3x2gr iv Cefotaxim 3x2 gr iv

 7/7/19 `12/7/19 `15/7/19
S   Sesak berkurang, demam (-) sesak Sesak-
O : Sakit sedang, compos mentis Sakit sedang, compos mentis Sakit sedang, compos mentis
  : Tensi : 110/70 Tensi : 110/80 Tensi : 110/70
  HR =N : 90x/menit,REIC HR =N : 90x/menit,REIC HR =N : 90x/menit,REIC
  R: 22 x/m R: 22 x/m R: 22 x/m
  S: 36.6 C S: 36.6 C S: 36.6 C
  SaO2 98% O2 3 lpm SaO2 98% O2 3 lpm SaO2 98% O2 3 lpm
JVP 5+2 cm H2O JVP 5+2 cm H2O JVP 5+2 cm H2O
Ronkhi -/- Ronkhi -/- Ronkhi -/-
Edema -/- Edema -/- Edema -/-
Kultur : staphylococcus aureus
Kultur : staphylococcus aureus Kultur : staphylococcus aur
I: 1300cc/24 jam I: 1600cc/24 jam
Lab (12/7/19) O: 1400cc/24 jam O: 1400cc/24 jam
Hb 11.6/ht 35.1/eri 4.04/leukosit B:-100cc/24 jam B:+200cc/24 jam
10470/trombosit 451000/DC
0/0/0/76/18/6/CRPkuantitatif:1.
13
1200cc/24 jam
O: 1400cc/24 jam
B:-200cc/24 jam
A : Hemodinamik Stabil Hemodinamik Stabil Hemodinamik Stabil
Failure (-) Failure (-) Failure (-)
Hepatitis C kronis

P : Terapi lanjutkan Cefotaxim 3x2gr iv Cefotaxim 3x2 gr iv

etiologi
 patogenesis
• The initial step in the
establishment of a
vegetation is endocardial
injury, followed by focal
adherence of platelets and
fibrin. Some organisms with
high virulence are capable
of infecting normal human
heart valves, such
as Staphylococcus aureus.
• The initially sterile platelet-
fibrin nidus becomes
secondarily infected by
microorganisms circulating
in the blood, either from a
distant source of focal
infection or as a result of
transient bacteremia from a
mucosal or skin source
Click icon to add picture
Mekanisme IE in iv drug user

Injection particular matter (talc) may cause

endothelial damage o tricuspid valve

Repetitiv use of injection drug may produce

cumulative subclinical damage to tricuspid valve

In process of drug injection patients may also inject

bacteria or fungi on surface of the skin
TATALAKSANA IE
Surgery indication

• Right HF secondary to severe tricuspid regurgitation

with poor response to diuretic therapy;
• IE caused by organisms that are difficult to eradicate
(e.g. persistent fungi) or bacteraemia for at least 7 days
(e.g. S. aureus, Pseudomonas aeruginosa) despite
adequate antimicrobial therapy; and
• Tricuspid valve vegetations > 20 mm that persist after
recurrent pulmonary emboli with or without
concomitant right HF
• Terima kasih