CASE BASED

DISCUSSION
Department of Internal Medicine
Sultan Agung Islamic University

ADVISOR: dr. H. M. Saugi Abduh, Sp.PD, KKV, FINASIM

Nama : DE Anisya Tri Ayu Berliana

NIM : 30101507419
 Identiity
• Name : Mrs. J
• Age : 57 years old
• Gender : Female
• Religion : Muslim
• Job : Housewife
• Address : Sawah Besar II 07/02 Kaligawe,
Gayamsari,Semarang.
• MR Number : 01416xxx
• Room : Baitulizzah 1
• Examination Date : 24th August 2020
 History Taking
❖ Main Problem
Epigastric pain
❖ History of recent illness
Patient came to the Emergency Room of Sultan Agung Islamic Hospital with
epigastric pain since 6 hour ago. The pain is like being burning, and it spread to left
chest and the back. Beside epigastric pain, the patient also has nausea and vomit 15
times and feel the dizziness. The patient tried to eat and drink but always throw it up.
The patient has a history of hypertension and DM but uncontrolled. Because the patient
often feel dizziness and stomach pain, she always consume paramex and traditional
medicine. 2 weeks ago the patient was hospitalized in Sultan Agung Islamic Hospital
with the same complaint of abdominal pain.
 History of Past Illness
❖ Same illness (+) 2 months ago History of family’s illness
❖ Hipertension (+) 1 year ago
❖ Heart disease (-) Socio-economic history: BPJS PBI
❖ Athsma (-)
❖ DM (+) 1 year ago
❖ Allergy (-)
❖ Smoking (-)
 Systemic Anamnesis
❖ Main Complains : Epigastric Pain
❖ Onset : 6 hours ago
❖ Location : Epigastrium
❖ Chronology : The patient suddenly feels pain in her stomach in 03.00 AM
early morning.
❖ Quality and Quantity : The pain is spread to the left chest and the back, and feels
like burning.
❖ Modification factor : -
❖ Another Complain : Dizzy, nausa and vomit
❖ Comorbid complains : Hypertension, DM.
 0
1
Physical
Examination
 Physical Examination
❖ General: weaknes, in pain.
❖ Awareness: E4M6V5 (GCS : 15)
❖ Vital sign:
Blood pressure : 209/108 mmHg
Pulse : 121x/mnt
Breath frequency : 30x/mnt
Temp : 36,2°C
❖ Body mass index:
Weight : 40 kg
Height : 140 cm
BMI : 20.4 kg/m2
Interpretation: Hipertensi,
Takikardi, Dyspneu
 PHYSICAL EXAMINATION
• Skin : itching (-), jaundice (-), pale (-).
• Head : headache (-)
• Eyes : blurred vision (-), red eyes (-), jaundice sclera (-/-)
• Ears : hearing loss (-), discharge (-)
• Nose : nosebleed (-), discharge (-)
• Mouth : cyanosis (-), thrush (-)
• Throat : pain swallow (-), hoarseness (-), difficult in swallowing (-)
• Neck : trachea deviation (-), lymph hypertrophy (-), JVP (normal)
• Chest : cough (-), sputum (-). Blood (-)
• Cardiac : chest pain (-), palpitations (-)
• Digestive : abdominal pain (+), nausea vomiting (+), turgor (+)
• Musculoskeletal : weak (-), rigid (-), back pain (-)
• Extremity : extremity edema (-)
INTERPRETATION :
Turgor skin (+),
abdominal pain,
nausea vomiting
 Thorax Examination
Inspection Dextra Sinistra
Static 30 RR : x/min, Hyper pigment (-), spider nevi RR : 30 x/min, Hyper pigment
(-), atrophy Pectoral Muscle (-), ICS Normal, (-),spider nevi (-),
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 (-), epigastric retraction (-) retraction ICS (-)

Palpation Palpable pain(-), tumor (-), Arcus costae angle Palpable pain (-), tumor (-), Arcus
< 900, enlargement of ICS (-), Stem fremitus costae angle < 900, enlargement of ICS
normal (-), Stem fremitus meningkat
Percution
Sonor Sonor

Auskultation Vesicular (+), Whezzing (-), Ronchi (-) Vesicular (+), Whezzing (-), Ronchi (-)
Interpretation =
Takipneu
 Thorax-COR Examination
INSPECTION Ictus cordis isn’t seen.

PALPATION Palpable (-), pulsus parasternal (-), sternal lift (-), pulsus epigastrium(-)

PERCUSSION • Upper borderline of heart : ICS II left sternal line

• Waist of heart : ICS III left parasternal line
• Lower right borderline of heart : ICS V linea sternalis dextra
• Lower left borderline of heart : ICS VI Linea midclavicula 2 cm to
lateral
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 ( -)

Interpretation =
Cardiomegaly
 Abdomen Examination
EXAMINATION RESULTS
Inspection Symmetrical, cicatrix (-), Striae (-), Vein’s enlargement (-),
Caput medusa (-), Spider nevi (-)
the right inguinal area is a bump, edema (-), reddish skin
color

Auscultation Peristaltic (+), Abdominal aorta’s bruits (-), Splenic Artery,

Femoral Artery (-)
Percussion Tympanic, Shifting dullness (-) Undulation test (-), Liver
dullness (-), Liver span (-), Traube’s space (tympanic)

Palpation Mass (-), Pain (+), Hepatomegaly (-), Liver, Kidney & Spleen
are normal, Splenomegaly (-)
Murphy’s sign (-)

Interpretation =
Epigastric pain
 Extremity Examination
Superior Inferior
Oedem -/- -/-

Pitting Oedema -/- -/-

Cyanotic -/- -/-

Cold Extremity -/- -/-

Capillary Refille >2s >2s

Clubbing Finger -/- -/-

Ulcer -/- -/-

Intepretation : Normal
 0
2
Additional
Examination
 ECG
(ELECTROCARDIOGRAPHY
EXAMINATION)
ECG
 Interpretation of ECG
● Rhytm : Sinus
● Regularity : Regular
● Frequency : 300:2,5=120 x/m
● Axis : lead 1 (+), AvF (+) (NAD)
● Transition zone : v4
● LVH : SV2 + RV5 ( 23 + 17= 40≥35) 🡪 LVH
● RVH : R V1/S V6= <1 🡪 normal

● Q patologis :-
● P wave : 0.08s
● PR Interval : 0,12 s (normal)
● QRS complex : 0,08 s (normal)
● T wave :-
● ST segment : ST depresi in V1,V2,V3,V4,V5

Interpretation : sinus tachicardy

regular,LVH and T inverted V1,V2,V3,V4,V5
 0
3
Laboratory
Examination
 Laboratory/23/08/2020
Examination Result Reference Value

Clinical Chemistry 2,2ng/L • <19ng/L, no chest pain 🡪

Troponin I rule out
• >100ng/L, rule in
• 19-100ng/lL (Re-check
troponin result after 3
hours, if T3-T0 >= 10ng/L
🡪 rule in
HEMATOLOGY EXAMINATION (BLOOD ROUTINE TEST)
23/08/2020
EXAMINATION TEST RESULT NORMAL VALUE

Hemoglobin 13.1 11.7-15.5

Hematocrite 38.7 33-45

Leukocyte 7.79 3.6-11.0

Erithrocyte 4.5 3.8-5.2

Thrombocyte 514 (H) 150-440

Intepretation :
Trombocytosis
HEMATOLOGY EXAMINATION (DIFF COUNT)
23/08/2020

EXAMINATION TEST RESULT NORMAL VALUE

Eosinofil % 0.5 (L) 1-3

Basofil % 0.6 0-1

Neutrofil % 70,8 (H) 50-70

Limfosit % 21,2 (L) 25-40

Monosit % 6,3 2-8

IG % 0.6

Intepretation :Eositopenia,
neutrofilia, Limphocytopenia
HEMATOLOGY EXAMINATION (ERITHROCYTE INDEX)

EXAMINATION TEST RESULT NORMAL VALUE

MCV 87,0 80-100

MCH 29,4 26-34

MCHC 33,9 32-36

Intepretation : Normal
 BLOOD CHEMICAL TEST
23/08/2020
EXAMINATION TEST RESULT NORMAL VALUE

Natrium 135 135-147

Kalium 3,40 (L) 3.5-5

Chloride 108,0 (H) 95-105

Intepretation : Hipokalemia, Hiperchloride

 BLOOD CHEMICAL TEST
24/08/2020
EXAMINATION TEST RESULT NORMAL VALUE
Ureum 10 10-50 mg/dL
Creatinin 0.48 (L) 0.60-1.10 mg/dL
SGOT (AST) 24 0-35 U/L
SGPT (ALT) 17 0-35 U/L

Intepretation : Low Creatinin

 BLOOD CHEMICAL TEST
26/08/2020 TIME : 06.28
EXAMINATION TEST RESULT NORMAL VALUE
HBA1C 7.00 (H) Normal <=5.4%
High Risk 5.5-6.4%
Suspect DM >=6.5
Fasting Glucose 100 70-110 mg/dL
Recent Blood Glucose 230 (H) <200 mg/dL

Intepretation : Hyperglicemia
 BLOOD CHEMICAL TEST
26/08/2020 TIME : 09:36
EXAMINATION TEST RESULT NORMAL VALUE
2 hours post prandial 126 70-130 mg/dL
glucose

Intepretation : Normal
 0
4
Radiology
Examination
 X-Foto Thotrax
23/08/2020

Cor: Apex to laterocaudal, flattener cardiac waist

Pulmo:
• increase vascular features
• Minimal infiltrat in left perihiler and right
pericardiac
No abnormality in diaphragma and costofrenicus
angle

Description :
Suspect Cardiomegaly (LV,LA)
Minimal infiltrat in left perihiler and right
pericardiac likely bronkopneumonia
DIGESTIVE SYSTEM ULTRASONOGRAPHY
26/08/2020 TIME: 05:58
 DIGESTIVE SYSTEM ULTRASONOGRAPHY
26/08/2020 TIME: 05:58
ABDOMEN USG
• Hepar : Size normal, reguler edge, increased ecogenicity, homogen parenchym, there is no nodul, Porta
vein and Hepaticavein is not widen.
• Intrabilliaris duct and extrahepatal duct is not widen.
• Vesica fellea’s wall is not thivk, no stones no sludge
• Pancreas, size is normal,parenchyme is normal, pacdreaticus duct is not widen
• Lien’s size is normal, parenchyme Is normal, lienalis venous is not widen
• Paraaorta is normal
• Right kidney’s size is normal, cortikomeduler line is normal, echogenicity is normal, PCS is not widen, no
stones/mass
• Left kidney’s size is normal, cortikomeduler line is normal, echogenicity is normal, PCS is not widen, no
stones/mass
• Bladder’s wall is not thick, no stones/mass
• Uterus : there is hipoecoioc lession, line is not clear in cervix untill uteri corpus(size 4,25 x 3,57 cm)

Description :
- Solid lession line is not clear in cervix until corpus uteri (size 4,25 x 3,75 cm) 🡪 suspect servix uterine
mass
- Fatty liver grade 1
- No abnormalities in other abdomen organs by sonography.
 0
5
Abnormalitas Data
Abnormal Data
History Taking
❑ Epigastric pain
❑ Vomitus >15 times
❑ Nausea
❑ Dizziness
❑ Turgor(+)
❑ Capillari refill >2 s
❑ Hypertension History (+)
❑ Diabetes mellitus history (+)
Physical Examination
❑ High blood pressure : 209/108
mmHg
❑ RR : 30x/minutes
❑ Pulse : 121x/minutes
❑ Cardiomegaly
❑ Epigastric pain
Lab
❑ Trombocytosis
❑ Eositopenia, neutrofilia,
Limphocytopenia
❑ Hipokalemia, hiperchloride
❑ Low creatinin
❑ hyperglicemia
ECG :
❑ sinus tachicardy regular,LVH and T
inverted V1,V2,V3,V4,V5
X-Ray :
❑ Cardiomegaly (LV,LA)
❑ Minimal infiltrat in left perihiler and right
pericardiac likely bronkopneumonia
 0
6
Problem List
 1.. Vomitus obs.
dyspepsia 2. Crisis Hypertensive 4. Susp Carsinoma Cervix

• Vomitus >15x/times
• BP : 209/108 mmHg • Solid lession line is not
• Nausea , dizzines
• Hypertension history (+) clear in cervix until
• Epigastric pain
corpus uteri (size 4,25 x
• History of dyspepsia
3,75 cm) 🡪 suspect ca
• Hiperchloride
servix uterine
• Pulse : 121x/minutes
• Trombocytosis
• RR : 30x/minutes 3. Diabtes Melitus
• Eositopenia, neutrofilia,
• Turgor (+), CRT >2detik tipe II
Limphocytopenia

• HbA1C: 7.0% Recent Blood

Glucoce: 230 mg/dL
• History of diabetes mellitus
 5. IHD 6. BRPN 7. Hipokalemia

ECG :
• Low kalemi🡪 3,40
❑ sinus tachicardy
regular,LVH and T ❑ Minimal infiltrat in left
inverted perihiler and right pericardiac
V1,V2,V3,V4,V5 🡪 likely bronkopneumonia
Iskemic Anterior
 Vomitus obs. Dyspepsia
Assessment:
❑ Dyspepsia (Fungsional dan Organic)
❑ Psikosomatis
❑ Crisis Hipertensi
IP Dx :
❑ Endoskopi
❑ CT Scan Brain
IP Tx :
❑ Pharmacology
⮚Inj, Ondansetron 8 mg
⮚Domperidone 1 mg 3x4
⮚Lansoprazole 2x30 mg
⮚Sucralfat syr 3x1
⮚Alprazolam 0,25 mg 1x1
⮚Infuse loading Ringer lactat 500 cc 🡪 20 tpm
⮚RL/Tutofusin
⮚Farbion 1x1
 ❑ Non pharmacology
⮚Drink much water
⮚Choose lower pottasium foods
⮚Avoid product with added salt
IP.Mx :
❑ Vital sign
❑ urine output measurement
IP.Ex :
⮚Drink much water
⮚Choose lower pottasium foods
⮚Avoid product with added salt
 Crisis Hypertensive
Assessment:
❑ Urgency Hypertensive 🡪 ICH
❑ Emergency Hypertensive
IP Dx :
❑ CT-Scan, CBC, BNP-NT Pro BNP, BUN and creatinin level, urine test, funduscopy,
liver function test.
IP Tx :
❑ Pharmacology
⮚PO Amlodipine 1x10 mg
⮚PO Irbesartan 1x150 mg
❑ Non pharmacology
⮚Reduce salt intake
⮚Reduce fat food intake
⮚Eat more vegetables and fruit
⮚Avoid stress
IP.Mx :
❑ Vital sign
❑Awareness
IP.Ex :
❑ Low salt food intake
❑ Avoid stress
❑ Low fat intake
❑ Exercise regularly
❑ Take the medicine properly
❑ Maintain blood pressure once a month
 MAP

MAP = S + 2D/3= 200+200/3= 133,3X25% = 33,25

Target = S – MAP = 200-33,25= 165
 Diabetes Mellitus type II
ASSESMENT
oComplication:
• ACUTE :
- Hypogliycemic
- Hyperglicemic
• CHRONIC :
Microangiopathy
- Diabetic Neuropathy
- Diabetic Retinopathy
- Diabetic Nephropathy
Macroangopathy
- Coronary Heart disease
- Peripheral Arterial disease
- Cerebrovaskuler disease
o Status glikemi
Ip Tx :
Non Pharmacological :
Low sugar diet

Pharmacological
Inj Humalog 10 unit
Metformin 500 mg 3x1

Ip Mx :
Random Blood Glucose
Fasting blood sugar
HbA1C
Assessment:
Carsinoma Cervix
❑ Squamous cell carcinoma
❑ Adenocarcinoma
❑ Staging of carcinoma
IP Dx :
❑ Colposcope (biopsy)
❑ X-Foto thorax
❑ CT-Scan Abdomen
IP Tx :
❑ Refer to oncologist
❑ Surgery (trachelectomy, hysterectomy)
❑ Radiation
❑ Chemotherapy
❑ Immunotherapy
IP.Mx :
❑ Vital sign
❑ X-foto Thorax
IP.Ex :
⮚Don’t smoking
⮚Do the therapy comprehensively
⮚Avoid multisexual partner
 IHD
Assessment
Pharmacology
Etiologi :
❖ Nitrokaf 2.5 mg 1x1
❖ Unstabel Angina
❖ Aspirin 80 mg 1x1
❖ Non ST Elevasi Myocard Infarction (NSTEMI)
❖ Bisoprolol 2.5-5 mg 1x1
IP Dx : Troponin T, Lipid Profile, Invasive angiography
❖ Fondaparinux 2.5 mg 1x1 ( for 5 – 8 days )
IP Tx :
❖ Clopidogrel 75 mg 1x1
Non Pharmacology Ip.Mx : ECG serial, Vital Sign
❖ Low Fat Intake Ip.Ex :
❖ High Fiber diet ✔ Reducing Emotional stress
✔ Reducing eat that food contain high cholesterol
 Bronchopneumonia
Assessment:
❑Etiology :
oBakteri :
Non spesifik 🡪 Strep. Pneumonia, Stap. Aureus, Haemophylus Influenza,
Spesifik 🡪 Mycobacterium TB
oVirus
oJamur
IP Dx :
• Pemeriksaan gram & kultur bakteri 🡪 non spesifik
• Pemeriksaan BTA 🡪 spesifik
IP Tx :
Non Pharmacological Treatment :
● Healthy nutrition
Pharmacological Treatment :
● Levofloxacin 750 mg 1x1
IP.Mx :
❑ HR
❑ RR
❑ Temperature
❑ Leukocyte Count
❑ Ronchi/crackles
IP.Ex :
❑ Tell the patients the cause of the disease, its transmission and its
complications
❑ Taking the medication regularly
 Hipokalemia
Assessment: IP Mx :
❑Status level hipokalemia (Mild) • Elektrolit
❑Complication: Aritmia • ECG
IP Dx : IP Ex :
• Px Elektrolit ⚫ Diet high calium intake
IP Tx : (banana, grape, avocado,
⚫Pharmacology : beans, potato
⚫ - KSR 1x600 mg
⚫Non pharmacology :
⚫Diet high calium intake (banana, grape,
avocado, beans, potato
Hitung jumlah kalium
Koreksi Kalium
- ∆ K : target kalium – kalium pasien
= 3.5 -3.4 = 0.1
- Defisit K : ∆K x BB x 0.8 = 0.1 x 40
x 0.8 = 3,2
HYPERTENSI
VE URGENCY
 Classification

Source : 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in
Adults, American College of Cardiology/ American Heart Association
Source : 2017 Guideline for the Prevention, Detection,
Evaluation and Management of High Blood Pressure in
Adults, American College of Cardiology/ American Heart
Association
Source : 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ ASPC/NMA/PCNA Guideline for the
Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary
Diagnosing

Source : 2017 Guideline for the Prevention,

Detection, Evaluation and Management of High
Blood Pressure in Adults, American College of
Cardiology/ American Heart Association
Hypertension : By Toni L. Ripley, Pharm.D., FCCP, BCPS, AHSCP-CHC; and Anna Barbato, Pharm.D., BCPS,
AHSCP-CHC
Management

Source : 2017
ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/
ASPC/NMA/PCNA Guideline for the Prevention,
Detection, Evaluation, and Management of High
Blood Pressure in Adults: Executive Summary
Source : 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ ASPC/NMA/PCNA Guideline for the Prevention,
Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary
Antihypertensive in patient with DM

Source : 2017
ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/
ASPC/NMA/PCNA Guideline for the Prevention,
Detection, Evaluation, and Management of High
Blood Pressure in Adults: Executive Summary
 Nonpharmacological
treatment

Source : 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults, American College of
Cardiology/ American Heart Association
DEHYDRATI
ON
RN(AAP) Clinical Decision
Tools ©2019 Saskatchewan
Registered Nurses
Association
RN(AAP) Clinical Decision
Tools ©2019 Saskatchewan
Registered Nurses Association
PREVENTION
DYSPEPSI
A
76
Penegakan Diagnosis

80
82
 Alarm symptom for dispepsia

1. Decreasing of weight gain > 10% without any reason

2. Progressive disfagia
3. Vomitus frequent
4. Gastrointestinal bleeding
5. Anemia
6. Fever
7. Epigastrium mass
8. Family history of ca gaster
9. Acute dispepsia on age 45
DIABETES
MELLITUS
 CLASSIFICATION DIABETES MELLITUS

Source : American Diabetes Association Standards of Medical Care in Diabetes-2020

 DIAGNOSTIC CRITERIA OF DIABETES
MELLITUS

Source : American Diabetes Association Standards of Medical Care in Diabetes-2020

DIAGNOSTIC CRITERIA OF DIABETES MELLITUS

Source : Konsensus Diabetes Mellitus Perkeni 2019

DIAGNOSTIC CRITERIA OF DIABETES MELLITUS

Source : Konsensus Diabetes

Mellitus Perkeni 2019
RECOMMENDATION OF TREATMENT IN
DIABETES MELLITUS

Source : Konsensus Diabetes

Mellitus Perkeni 2019
TREATMENT OF DIABETES MELLITUS USING
OHO

Source : Konsensus Diabetes

Mellitus Perkeni 2019
TREATMENT OF DIABETES MELLITUS USING
INSULIN AND ITS INDICATIONS

Source : Konsensus Diabetes

Mellitus Perkeni 2019
 THE TARGET OF A1C & THE TARGET OF
CONTROLLING DIABETES MELLITUS

Source :
Konsensus Diabetes Mellitus Perkeni 2015
American Diabetes Association Standards of Medical Care in Diabetes-2020
 PHARMACOLOGIC APPROACH RELATED WITH
T2DM

Source :
American Diabetes Association Standards of Medical Care in Diabetes-2020
 PHARMACOLOGIC APPROACH RELATED WITH
T2DM

Source :
American Diabetes Association Standards of Medical Care in Diabetes-2020
Source :
American Diabetes Association Standards of Medical Care in Diabetes-2020
Source :
American Diabetes Association Standards of Medical Care in Diabetes-2020
Journal of the Pakistan Medical Association: Sanjay Kalra ,2016,
Classificationofnon-insulinglucoseloweringdrugs
PERKENI : Pedoman Pengelolaan dan Pencegahan Diabetes Mellitus Tipe 2 Dewasa di Indonesia
2019
ACUTE COMPLICATION
CHRONIC COMPLICATION
123
American Association Diabetes:
Pharmacologic Approaches to Glycemic
Treatment Diabetes Care Volume 43,
Supplement 1, January 2020
PERKENI : Pedoman Pengelolaan dan Pencegahan Diabetes Mellitus Tipe 2
Dewasa di Indonesia 2019
PERKENI : Pedoman Pengelolaan dan Pencegahan Diabetes Mellitus Tipe 2
Dewasa di Indonesia 2019
PERKENI : Pedoman Pengelolaan dan Pencegahan Diabetes Mellitus Tipe 2
Dewasa di Indonesia 2019
Pharmacodynamic Profiles of a Rapid Insulin Analog (insulin Pharmacodynamic Profiles of Faster Aspart and Insulin Aspart
lispro) and Regular Insulin

NCBI :Insulin – Pharmacology, Therapeutic Regimens, and Principles of Intensive Insulin

Therapy, 2019
 Pharmacodynamic Profiles of Long-Acting and Intermediate-
Acting Basal Insulins

NCBI :Insulin – Pharmacology, Therapeutic Regimens, and Principles of Intensive Insulin Therapy,
2019
CARSINOMA CERVIX
ESMO Patient Guide Series :
based on the ESMO Clinical
Practice Guidelines : Cervical
Cancer
WHO 2013 Comprehensive cervical cancer prevention and control:a healthier future for girls and women
 WHO 2013
Comprehensive cervical
cancer prevention and
control:a healthier future
for girls and women
ESMO Patient Guide Series : based on the ESMO Clinical Practice Guidelines : Cervical Cancer
ESMO Patient Guide Series : based on the ESMO Clinical Practice Guidelines : Cervical Cancer
 ESMO Patient Guide Series :
based on the ESMO Clinical Practice
Guidelines : Cervical Cancer
ESMO Patient Guide Series : based on the ESMO Clinical Practice Guidelines : Cervical Cancer
ESMO Patient Guide Series : based on the ESMO Clinical Practice Guidelines : Cervical Cancer
BRONCHOPNEUMONIA
 ETIOLOGY OF CAP

Source : Harrison’s Pulmonary & Critical Medicine

CLASSIFICATION
CLASSIFICATION
CLINICAL MANIFESTATION &
DIFF.DIAGNOSIS

Source : Harrison’s Pulmonary & Critical Medicine

CLINICAL & ETIOLOGICAL
DIAGNOSIS
CLINICAL & ETIOLOGICAL
DIAGNOSIS
CLINICAL & ETIOLOGICAL
DIAGNOSIS
RELATED SCORING &
COMPLICATIONS
 RELATED
SCORING &
COMPLICATIO
NS
TREATMENT
TREATMENT
GUIDELINE IN TREATING PNEUMONIA IN ADULT
(IMPORTANT THINGS TO KNOW)
TREATMENT FOR CAP
BASED ON SEVERITY
GUIDELINE IN TREATING PNEUMONIA IN ADULT
(INPATIENT SETTING)
GUIDELINE IN TREATING PNEUMONIA IN ADULT
(DUE TO INFLUENZA)
 GUIDELINE IN TREATING PNEUMONIA IN ADULT
(THE APPROPRIATE DURATION OF ANTIBIOTICS USAGE IN PATIENT)
GUIDELINE IN TREATING PNEUMONIA IN ADULT
(OUTPATIENT SETTING)
GUIDELINE IN TREATING PNEUMONIA IN ADULT
(INPATIENT SETTING)
GUIDELINE IN TREATING PNEUMONIA IN ADULT
(INPATIENT SETTING)
IHD
 Thrombus Formation and ACS
Plaque Disruption/Fissure/Erosion

Thrombus Formation

Old
Terminology: UA NQMI STE-MI

New Non-ST-Segment Elevation Acute ST-Segment

Terminology: Coronary Syndrome (ACS) Elevation
Acute
Coronary
Syndrome
(ACS)
 ACS
171
Chest pain

ST elevation ST depression
ECG ST segment

Bio-chemistry Troponin rise / Troponin

fall normal

Diagnosis

STEMI NSTEMI UA

Adapted from Hamm CW et al. Eur Heart J 2011;32:2999 – 3054, Davies MJ. Heart 2000;83:361–366
GRACE SCORE : 69
cTnI
- Meningkat : 2 – 8 jam
- Puncak : 10 – 24 jam
- Menurun : Hari ke 7
cTnT
- Meningkat : 2 – 8 jam
- Puncak : 10 – 24 jam
- Menurun : Hari ke 14

Normal : cTnI : < 1,0 μg/L

cTnT : < 0,1 μg/L
Sampel: Plasme Heparin
 LDH
cTnI

CK-MB

Myoglobin

Reference Interval

0 1 2 3 4 5 6 7 10
Days after onset of AMI

Marker Initial Elevation Peak Return to Baseline

Troponin-I 4 – 6 hours 24 hours Up to 10 days
CK-MB 4 – 8 hours 12 – 24 hours 3 – 4 days
Myoglobin 2 – 4 hours 18 hours < 24 hours
LDH 10 – 12 hours 48 – 72 hours 7 – 10 days
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