CASE-BASED DISCUSSION

BY:
DAFFA JOKO N W (30101507415)

ADVISOR:
DR. SAUGI ABDUH, SP. PD., KKV, FINASIM
PATIENT IDENTITY

 Name : Mrs. S
 Age : 43 years old
 Gender : Female
 Religion : Moeslem
 Job : Farmer
 Address : Wonosami 05/03, Banjarejo, Blora
 MR Number : 01404732
 Room : Baitulizzah 2/M2
 Entry Date : January 27, 2020
HISTORY TAKING

 Main problem
 Dyspneu

 History of presnt illness

 Patient came to Emergency Unit of Sultan Agung Hospital with dyspneu since 10 days ago. For the first time, dyspneu
occured while the patient was doing mild activity. She felt ortopneu and paroxismal nocturnal dyspneu. Then dyspneu
reduced at rest. She said that her legs were swelled, abdominal enlargement without pain since 10 days ago before coming to
hospital. She felt tired easily. Previously patients were treated Blora Hospital with the same conditions and finally referred to
Islamic Hospital Sultan Agung Semarang. This condition was persisting until the patient came to hospital.
HISTORY OF ILLNESS

 History of previous illness  History of family’s illness

 Asthma:  Asthma:
 Pneumonia  Pneumonia
 Arrhythmia  Arrhythmia
 Valvular heart disease:  Valvular heart disease:
 Congestive heart disease  Congestive heart disease
 Anemia:  Anemia:

 Socio-economic history:
 BPJS PBI
SISTEMIC ANAMNESIS

Chief Complains : Dyspneu

Onset : 10 days ago

Location : Chest

Chronology : 10 days ago occured dyspneu while doing mild activity and worsten

Quality and Quantity : patients feel dyspneu when mild activity and worsent at night and potitional changes

Modification factor: reduce at rest.

Comorbid complains : swelling extremities

PHYSICAL EXAMINATION
Interpretations: takipneu, normoweight
 General: weaknes, dyspneu
 Awareness: E4M6V5 (GCS : 15)
 Vital sign:
 Blood pressure : 102/79 mmHg
 Pulse : 51 x/mnt
 Breath frequency : 24 x/mnt
 Temp : 36,3°C
 Body mass index:
 Weight : 45 kg
 Height : 150 cm
 BMI : 20 kg/m2
GENERAL EXAMINATION
Interpretations: increasing JVP

 Head : msocephal
 Eyes: Anemic Conjungtiva (-/-),Icteric sclera (-/-)
 Nose : symmetric, secret (-), nostril Breath (-)
 Ears : Normal Shape, discharge (-/-)
 Esophagus : Hyperemic (-), pain devour (-)
 Mouth : Cyanosis (-), fector hepatikum (-)
 Neck : Trakhea deviation (-), Lymph Hypertropy (-), Increasing JVP 5 ± 3cm
THORAX EXAMINATION
INSPEKSI DEXTRA SINISTRA

Static RR : 24x/min, Hyper pigment (-), spider nevi RR : 24x/min, Hyper pigment
(-), atrophy Pectoral Muscle (-), ICS Normal, Diameter AP < LL (-),spider nevi (-),
ICS Normal, Diameter AP < LL

Dynamic Up and down of hemitoraks D=S, abdominothorakal breathing, (-), Up and down of hemitoraks D=S, abdominothorakal
muscle retraction of breathing (-), breathing (-), muscle retraction of breathing(-),
retraction ICS (-), epigastric retraction (-) retraction ICS (-)

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

Percution dullness dullness

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

Interpretations: lung edema

CARDIAC EXAMINATION

Inspection : Ictus cordis seen.

Palpation : Ictus cordis is palpable at ICS VI 1 cm lateral from linea midclavicularis sinistra, thrill (+)
with three finger, epigastric 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, mid clavicle line

Interpretations: cardiomegaly
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 (-)

Interpretations: murmur
 ABDOMEN EXAMINATION

Inspection : symetric, sycatric(-), striae(-), caput medusa (-).

Auscultation : peristaltic (+), 20 x/mnt
Percussion : tympani, side of dullness (+), shifting dullness (+)
•Liver : dullness(+), right liver span 10 cm, left liver span 4 cm
•Spleen : Throbe space percussion (+)  tympani
Palpation
•Superfisial : tight (-), mass (-), epigastrial pain (-)
•Deep : epigastric pain (-), kidney, and spleen weren’t palpable, liver were palpable enlargement

Interpretations: hepatomegaly
EXTREMITY EXAMINATION

Ekstremitas Superior Inferior

• Oedema -/- +/+
• Cold -/- -/-
• Jaundice -/- -/-
• Capillary 2 second 2 second

refill

Interpretations: oedem lower

extremity
LABORATORY EXAMINATION
 TEST RESULT NORMAL RESULT
Jan 27, 2020
HEMATOLOGY
Interpretations:
Hb 13,5 11.7-15.5
• Hipokalemia
Hematocrit 39,8 33-45
Leukocyte 6,95 3.6-11
Trombocyte 186 150-440
Blood type A/+
IMUNOLOGY
HBsAg Non reactive Non reactive
BLOOD CHEMICAL
Natrium 141.1 135-147
Kalium 3,41 3,5-5
Chloride 102,2 95-105
GDS 131 75-110
Ureum 17 10-50
Blood creatinin 0,87 0,6-1,1
ECG Jan 28, 2020
 Interpretations:
INTERPRETATIONS
• Iskemia inferior
 Rhytm : ventricular
• AF
 Regularitas : Iregular
 Frekuensi : 60 x/menit
 Axis : lead 1 = +; AvF = +  NAD
 Zona Transisi : V4
 Gelombang P : -
 Interval PR : cannot be evaluated
 Komplek QRS : 0,08 detik
 Gelombang Q : Q patologis
 Segmen ST : ST depressed in lead II, III, AVF
 Gelombang T : inverted in lead II, III, AVF,
 CHEST X-RAY
Interpretations:
• Kardiomegali (LV, LA, RA),
Disertai penonjolan konus LA
pulmonalis

RA

LV
 TEE
Interpretations:
• MR moderate
• MS
• LAA: trombus (+)
 ECHOCARDIOGRAPHY
Interpretations:
• Hipokinetik segmental
• Fungsi LV sistolik menurun EF:
45%
• Dilatasi LA
• TR moderate
• PH moderate
• MS severe
• AR mild
 ABNORMAL DATA

History Taking Physical Examination : TEE :

17. MR moderate
1. dsypneu, 6. Takipneu 18. MS
2. Swelling extremities, 7. Increasing JVP 19. LAA: trombus (+)

3. Orthopneu 8. Lung edema

Echocardiography :
4. Paroxysmal nocturnal 9. Cardiomegaly
20. Hipokinetik segmental
10. Edem extrimities 21. Fungsi LV sistolik
dyspneu
menurun EF: 45%
11. Hepatomegaly
5. Felt tired easily 22. Dilatasi LA
23. TR moderate
ECG : Chest X-Ray : 24. PH moderate
Lab: 13. AF 16. Kardiomegali (LV, 25. MS severe
14. Iskemia LA, RA), Disertai 26. AR mild
12. Hiperglikemi inferior penonjolan konus
15. Hipokalemi pulmonalis
PROBLEM LIST

Congestive Heart Failure: Pulmonal Hypertension

Ischemic Heart Disease

Atrial Fibrilation

Valvular Heart Disease:

MS severe, TR moderate, AR
Hipokalemia
mild
CONGESTIVE HEART FAILURE
 Assesment
 Anatomi: Cardiomegaly (LV, LA, RA), dilatation LA
 IP Mx
 Fungsional: NYHA IV
 Vital sign
 Etiology: IHD, valvular heart disease
 ECG
 IP Dx  IP Ex
 BNP (≥ 35 pg/mL) dan Pro-BNP (≥ 125 pg/mL)
 Bed Rest/Restriction of physical activity
 IP Tx  Reducing Emotional stress
 Furosemide 3x1 amp IV (20mg/2mL) give when the sistolyc blood  Routine consumption drugs
pressure more than 100 mmHg
 Sit position or a half sleep position
 Bisoprolol 2,5-5 mg 1x1
 Restriction fluid (max 1L/day)
 Spironolactone 25 mg 1x1
 Diviti (Low molecular weight heparin) SC 1x1
ISCHEMIC HEART DISEASE

 IP Mx:
 Assesment
 Vital sign,
 UAP
 ECG serial
 Stable angina
 IP Ex:
 IP Dx:
 Explain about the disease
 Cardiac troponin,
 Bed rest
 Invansive coronary angiography

 IP Tx:
 Nitrocaf 2,5 mg 1x1
 Aspirin 80 mg 1x1
 Bisoprolol 2,5-5 mg 1x1
VALVULAR HEART DISEASE

 Assessment
 Complication :  IP Mx:
 Atrial fibrillation
 Hemodynamic system
 Thromboembolism disease
 Critical limb ischemic
 IP Ex:
 ACS
 Bed rest
 IP Dx:
 Avoid heavy activities
 CHA2DS2-VASc (+2)

 IP Tx
 Repair or Replacement of valvular
PULMONAL HIPERTENSION

 Assesment
 IP Mx:
 Cardiac : VHD
 Vital sign
 Non cardiac
 Haemodinamic system
 IP Dx:
 ECG
 Right cardiac cateterization
 IP Ex:
 IP Tx:
 Bed rest
 Pharmacological : 60 mg of diltiazem three times a day, Sildenafil 25mg 2x1
 Avoid heavy activities
 Non Pharmacological: Oxygen NRM 5L
HYPOKALEMIA
 Assesment: -
 IP Dx: -
 IP Tx:
 Formula: Kdeficit (in mEq/ml) = (Knormal lower limit − Kmeasured) × kg body weight × 0.3

 Kdeficit (in mEq/ml) = (3,5-3,41) x 45 x 0,4

 Kdeficit (in mEq/ml) = 14,7 mEq/ml -> 15 ml KCl

 Each ml contains K 1 mEq/ml

 KSR 600 mg 1x1

 IP Mx:
 Vital sign
 ECG
 Blood Chemical

 IP Ex:
 Bed rest
ATRIAL FIBRILATION

 Assesment
 IP Mx:
 Etiology:
 Vital sign
 Valvular heart disease
 ECG
 Non valvular
 INR (target: 2-3)
 IP Dx:
 CHA2DS2-VASc Score(2), HAS-BLED Score
 IP Ex:
 Bed Rest
 IP Tx:
 Warfarin 2 mg 1x1
 Bisoprolol 2,5-5 mg 1x1
SOURCE
CHF
ISCHEMIC HEART DISEASE
VHD
PULMONAL HYPERTENSION
HYPOKALEMIA
ATRIAL FIBRILATION
ANTICOAGULANT