Case Based Disscusion

Adviser : dr.Saugi Abduh, Sp.PD

By : Galleta selena boer

01.208.5661 FK UNISSULA 08

PATIENTS IDENTITY
Name Age Sex Religion Work Adress No.Mr Room Entry Date Date Out : Mrs.N : 52 years old : Female : Moslem ::Jln.Penjaringan Rt 02 Rw 01,east Semarang : 1109060 : B.Izzah 1 (410.5) : March 2th, 2013 : March 11th, 2013

ANAMNESA
Chief Complain Dyspneu
History Taking
Patient come to hospital with main complaint is dyspneu. She felt dyspneu (+) when she was doing common activity, and felt better after take a rest or in half sit position and productive cough (+) since 1 week ago. she felt chest discomfort. Last night when she cough sprinkling of blood came out (hemoptoe). Paroksismal nocturnal dyspneu (+) she cant sleep well everynight, His body fell weak, patient also feel her legs are swelling. Patient also feel nausea (+) when she eat and drink. Theres no vomit. Decreased appetite/anorexia (+). Patient feel insomnia for last 2 days. Defecate and urination are normal.

History of Illness
History of previous illness
Never felt like this before Hypertension history (+) Familys history of disease since 2 years ago Hypertension history (-) DM history (-) DM history (-) Asthma history (-) Asthma and alergy Alergy history (-) history (-)

Sosio-Economic History : Hospital cost certified by JAMKESMAS Economic Impression : poor

 Vital Sign :
BP = 200/100 mmHg HR = 100x/min RR = 28x/min T = 36,4

General Skin Head

: dyspneu (+) legs swelling (+) : itching (-), jaundice (-), pale (-), slick (-) : headache (-) Eyes : blurred vision (-), red eyes (-), conjungtiva anemic (-/-) icteric sclera (-/-) Ears : discharge (-), hearing loss (-) Nose : nosebleed (-), discharge (-) Mouth : Cyanosis (-), thrush (-), bleeding gums (-) Throat : pain swallow(-), hoarseness (-), difficult in swallowing (-)

Neck : Trakhea deviation (-), Lymph Hypertropy (-),enlargement of the gland (-) Chest : cough (+), sputum (+), blood (-) Cardiac : chest pain (-), palpitations (-) Digestive : abdominal pain (-), decrease appetite (+),nausea (+), vomiting (-), black diarrhea (-) more than 10 times a day, defecate/micsi (+/+) Musculoskeletal : weak (-), rigid (-), back pain (-) Extremity : Oedem of lower extremity (+), Oedem of upper extremity (-)

General Status
General

: Dyspneu (+), legs swelling (+)

Awareness

: composmentis

Vital Sign
o Blood Pressure

: 200/110 mmHg

o Heart rate

: frequency. 100x/minutes, regural ritmict,

strong amplitudo, same equality, elastic artery wall, pulsus alternans (-), pulsus defisit (-)
o Respiration Rate o Temp

: 28x/minutes : 36,4o C

 Nutrient stat BMI

Head Eyes Nose Ears Throat Mouth Neck Extremity upper extremity (-)

: weight = 48kg, Height = 158cm : BB(kg)/TB(m) =48/(1.58)=19.22 (normoweight) : mesocephal, alopesia (-) : anemic conjugtival (-/-), Icteric sclera (-/-) : Symetric, secret (-), nostril breath (-) : normal shape, discharge (-/-) : hyperemic (-), pain devour (-) :cyanosis (-), dry lips (-) : Trachea deviation(-),Lymph hypertropy (-) : Oedem of lower extremity (+), oedem of

EXAMINATION

Chest Examination-Lung ANTERIOR POSTERIOR

RR : 28x/min, thoracal breathing,Hyperpigmentatio n (-), spider nevi (-), atrofi M. Pectoralis (-), Hemithoraks D=S, ICS Normal, Diameter AP < LL Up and down of hemitoraks D=S ,muscle retraction of breathing (-), retraction ICS (-) Palpation pain (-), mass (-), Arcus costae angle < 900, enlargemnet of ICS (-), Sterm fremitus D=S Sonor (+) Vesicular (+), Whezzing (-), Ronchi (+) all area of lung
Dyspneu, susp.bronchopneumonia

Inspeksi Static Dinamic

RR : 28x/min, thoracal breathing, Hiperpigmentasi (-), spider nevi (-), Hemithoraks D=S, ICS Normal, Diameter AP < LL Up and down of hemitoraks D=S, muscle retraction of breathing (-), retraction ICS (-) Palpation pain (-), mass (-), Sterm fremitus D=S

Palpation

Percution Auskultation
Interpretation

Sonor (+) Vesicular (+), Whezzing (-), Ronchi (+) all area of lung

CARDIAC
Inspection : Ictus cordis seen at ICS V linea mid clavicula sinistra Palpation : Ictus cordis is palpable at ICS linea mid clavicula sinistra , thrill (-), pulsus epigastrium (-), pulsus parasternal (-), sternal lift (-). Percussion : dull sound Upper borderline of heart Waist of heart

: ICS II linea sternalis sinistra : ICS III linea parasternalis sinistra Lower right borderline of heart : ICS V linea sternalis dextra Lower left borderline of heart : ICS V linea mid clavicula sinistra

Interpretation : susp.Cardiomegali (LV)

 Auskultasi Aorta valve

Pulmonal valve Trikuspidal valve Mitral valve

: S1 & S2 standart, additional sound (-), AI<A2 : S1 & S2 standart, additional sound (-), P1<P2 : S1 & S2 standart, additional sound (-), T1>T2 : S1 & S2 standart, additional sound (-) M1>M2

Abdomen
Inspection : Symetric, sycatric(-), striae(-), enlargement of vena (-), caput medusa (-), hernia (-), inflamation (-), aorta pultation (-), mass (-). Auscultation : Peristaltic (+), noise of aorta (-) Percussion : tympani, side of deaf (-), shifting dullness (-) Hepar : deaf(+), liver span dextra 11 cm, liver span sinistra 6 cm Lien : troube space perkusi (+) tympani (n) Palpation : Superfisial : abdominal pain (-), massa (-), muscle guarding (-). Deeper : abdominal pain (-) , rebound tenderness (-), hepar, kidney & lien arent palpable, Murphys sign (-), aorta pultation (n)

Interpretation : Normal

Ekstremities superior - Oedem -/- Akral dingin -/- Reflek fisiologis +/+ - Reflek patologis -/- Ikterik -/Interpretation : Oedem (+)

inferior +/+ -/+/+ -/-/-

LABORATORY TEST

HEMATOLOGI
02/03/2013 Hb HT Leukosit 6.8 g/dl (L) 21.5 % (L) 11,33 ribu/uL (H) 04/03/2013 9.1 g/dl (L) 28.2 % (L) 15.40 ribu/uL(H) 05/03/2013 9.4 g/dl (L) 29.2 % (L) 12.7 ribu/uL (H)

08/03/2013
8.0 g/dl(L) 25.9 % (L) 6.4 ribu/uL

Trombosit 332 ribu/uL

261 ribu/uL

272 ribu/uL

201 ribu/uL

Gol darah/Rh : O/ + IMUNOSEROLOGI HBsAg Kualitatif (-)

KIMIA
GDS Ureum

2/3/2013
132 mg/dl (H) 322 mg/dl (H)

5/3/2013
105 mg/dl (H)

8/3/2013
55 mg/dl (H)

Creatinin

13.72 mg/dl (H) 5.30 mg/dl (H)

3.46 mg/dl (H)

SGOT SGPT

23 U/I 30 U/I

KIMIA
Uric Acid

02/03/2013 14.9mg/dl H

04/03/2013

Cholesterol
Trigliserid

205 mg/dl (H)

117 mg/dl 57 mg/dl 79 mg/dl

Total Protein Albumin

Globulin Natrium Kalium Calcium Chloride Phosphat an organik

6.83g/dl
3.69g/dl 3.14g/dl 137.8mmol/l 7.19mmol/l 8.5mg/dL 110.4mmol/L 5.0mg/dL H L H

HDL Cholesterol direct LDL Cholesterol direct Bilirubin Total Bilirubin Direct
Bilirubin Indirect Fe TIBC

0.56 mg/dl
0.16 mg/dl 0.4 mg/dl 93 umol/l 313 umol/l

LABORATORY TEST
Interpretation : Anemia Leukositosis Hyperglycemia Hypercholesterol Hyperkalemi Hypokalsemia Hyperkloremia azotemia

LFG/FGR
(140-age) x Weight = 72 x creatinin plasma

(140-52) x 45 = 72 x 3,46 3960 = 15,89 x 0,85 = 13,5 ml/mnt/1,73m 249,12 Interpretation : (derajat V/Kidney Failure)

6/3/2013 Macroscopic protein reduksi Bilirubin Colour Reaksi/PH Benda keton Urobilinogen Microscopic Epitel sel Eritrosit Leukosit Silinder Parasit Bakteri Jamur Kristal Benang mukus

Urine 30 mg/dl (-) (-) Yellow 5.5 (-) 0.2 mg/dl 26-28/ LPK 5-7/LPB 25-37/LPB (-) (-) (-) (-) (-) (-)

Interpretation: Hematuria (> 3 eritrosit/LPB) Pyuria

X-RAY

Interpretation
Cor :
Cardiomegali (LV/Left Ventricle), Elongatio aorta

Pulmo:
Brochopneumonia duplex

USG ABDOMEN

Interpretation : kidney :
atrofi kidney/renal dextra et sinistra Increase ekogenitas of corteks cronic progress both of kidney (CKD)

ECG

ECG
1. 2. 3. 4. 5. Rhytme : reguler Frecuency : 1500 / 13 kk = 115 x/mnt Axis : NAD Transition Zone: V3 Waves Morphologic
P waves PR Interval QRS Comp ST Segment T waves : 0,08 (2kk) : 0,16 (4kk) l (0,16-0,20 s) : 1 kk (0,06-0,12 s) : Normal (iso elektris) Elevation (-), depression (-) : T inverted V3-V6

Interpretation : Iskemik anterolateral,sinus tachycardi (> 100x/mnt)

Data Abnormality
Anamnesis :
Hemoptoe Dyspneu Cough Nausea Decreased appetite

Advance Examination: Lab: Anemia Leukositosis Hyperglycemia Hypercholesterol Uricemia Hyperkalemi Hypokalsemia Hyperkloremia azotemia

Physic Examination : BP:200/110 Oedem of lower extremity (+) Pulmo : Ronchi (+) all area of lung, (Dyspneu,

susp.bronchopneumonia)
Cor : Ictus cordis at ICS V linea mid clavicula sinistra (in inspeksi,palpation,percusion) ,Susp.Cardiomegali (LV)

X-Ray cardiomegali (LV) Bronchopneumonia duplex USG abdomen : Atrofi both of kidney Increase ekogenitas of corteks cronic progress both of kidney (CKD) ECG: Iskemik anterolateral,

PROBLEM LIST
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. CHF NYHA III Hipertension Grade II Bronchopneumonia duplex CKD Edema lower extremity Hemoptoe Anemia Hyperuricemia Hypercholesterol Hyperkalemi Hypokalsemia

CHF NYHA IV
Assesment :
Anatomic Dx (LVH,LAH) Etiologic Dx (HHD,IHD,Cardiomiopathy) Dislipidemi

IP.Dx : Echocardigraphy, profil lipid IP.Rx : Non Farmacology

Bed rest (1/2 sit down position) Diet :

Diet low salt < 1 gr/day

Farmacology

O2 2-3 L/m Captopril 2x 12,5 mg Digoxin 2 x tab Spironolacton 2x 25 mg Furosemid 1x 20mg IV

IP.Mx : Vital sign, Fluid Balanced, Electrolit lab, electrocardiograpy

Ip Ex: Just take food from the hospital Avoid difficult/hard activity Avoid fried food Avoid drink and eat too much Reduce salt intake (max 1 spoon/day) and Stop alcohol and cigarette Consumption drug regularly Routine check of blood pressure

Hypertension Grade II
Ass : retinopati hipertensi, stenosis a.renalis IP Dx : Funduscopy, angiografi renal Ip Rx : Non Farmacology

a. b.

Diet low fat Diet low salt < 1gr/hr

Farmacology

IpMx: Vital sign, effect target organ ec hipertension

Captopril 2 x 25mg Amlodipine 1 x 10mg

IP.EX :

Reduce salt intake and Avoid alcohol,coffe and cigarette Mild Exercise at least 30 minute in everyday Consumption drug regularly Routine check of blood pressure.

EDEM PULMO
Ass : Treatment emergency condition IP Dx : Ip Tx : Non Farmacology Farmacology

Bed rest (1/2 sit down position) Bed rest, Reduce Na and water intake O2 2-3 L/m Loop diuretic : Furosemid 1x 2A(20mg) evaluation if still ronkhi give 2-4 A

IpMx: clinical apperance, X-Ray

IpEx : reduce Na and water intake, avoid factor caused edema pulmo

Bronchopneumonia Duplex
Ass : Spesific or non spesific bronchopneumoni IP Dx : BTA sputum, kultur sputum, gram stain Ip Rx : Non Farmacology
Bedrest Chest physiotherapy

Farmacology
Inf RL 20 tpm O2 2-5 l Azithromycin 1 x 1A Ciprofloxacin 1x 1A Dextromethorphan 3 x 1 tab Ventolin inhaler Efedrin 2 x 1 tab

IpMx: vital sign, SaO2, general condition, laboratory finding Ip Ex: take a rest for enough time, avoid alcohol

CKD
Ass Hiperkalemia, Perikarditis, Asidosis metabolic, Osteodistropi ginjal, Sepsis, Neuropati perifer, Ip Dx : Nephrostogram, blood gas analyz Ip Tx Non Farmakology : Diet low protein 0,6-0,8g/kgBB/hari = 48g/day Diet low salt 1 gram Diet fluid 600 + how much urine mL/hari Farmakology : Hemodialisa SF 3 x 300 mg Vit. C 1x 500mg CaCO3 3 x 50mg Ip Mx : routine blood, Ureum kreatinin, uric acid serum, analyze urine, blood gas analyze, elektrolit, imunodiagnosis, elektrolit, Ip Ex : Hemodialisa Regulary, go to the dokter regulary, life style

Edema lower extremity

Ass : IP Dx : Ip Tx : Non Farmacology
Bed rest, Local pressure, Reduce Na and water intake

Farmacology
Loop diuretic : Furosemid 1x 1A(40mg) Tiazid : hidroklortiazid 1x 1 tab(25mg)

IpMx: clinical apperance,laboratory finding

IpEx : reduce Na and water intake, avoid factor caused edema

Hemoptoe
Ass : IP Dx : Ip Tx : Non Farmacology
Fluid diet Warm drinking Bed rest

Farmacology
Antitusif : codein HCL (10mg) 3 x 1

IpMx:
Clinical apperance

Anemia
Ass :Anemia Hipokromik Mikrositer, Normochrome Normocyte Anemia IP. Dx:MCV,MCH,MCHC IP. Tx: Farmakologis
PRC transfusion 2 bag SF 3 x 200 mg (30minutes before meal) Vit. C 1x500 mg

IP. Mx: Clinical apperance,Hb Value,side effect of transfusion IP. Ex : medication regulary, bed rest,

Hyperuricemia
Ass : IP. Dx : IP. Tx : Terapi Non Farmakologis Control uric acid, diet low purin Terapi Farmakologis Allopurinol 1x 100mg IP. MX : Uric Acid,Vital Sign,General Condition IP. Ex : Control uric acid, maintenance weight, avoid obesity Diet low purin, non-alkohol intake Exercise regulary Control to the docor regulary

Hiperkalemia
Ass : IP Dx : Ip Tx : Non Farmacology
Avoid food with high kalium

Farmacology
Furosemid 1x1A Kalsium glukonat 20-30 mL IV perlahan Atau Natrium polistiren sulfonat 3x15mg

IpMx:
Laboratory finding, clinical apperance (muscle weakness),ECG

Hipokalsemia
Ass : IP Dx : Ip Tx : Farmacology
Ca Chloride 1x500mg IV

IpMx: clinical apperance, laboratory findings,ECG

Hiperkolesterol
Ass : IP Dx : Ip Tx : Non Farmacology Diet low fat Farmacology Simvastatin 10 mg (0-0-1) IpEx: Reducing high cholesterol food Exercise regularly according to the patients ability

FOLLOW UP
Dat e 3/3 /13 4/3 /13 5/3 /13 6/3 /13 7/3 /13 BP HR RR TE Hb MP 36. 2 36. 8 36. 4 36 37. 1 Leu Ur Cr Uric acid 14.9 Kali um 7.19 Cal Chlori ciu de m 8.5 110.4 Chol este rol 205 180/120 160/100 200/110 140/90 140/110 80 80 10 0 80 10 0 20 20 28 20 20 6.8 1.113.000 9.1 261.000 9.4 272.000 105 5.30 322 13.7 2

8/3 /13
9/3 /13
10/3 /13 11/3 /13

180/100
190/120 160/100 140/100

90
10 0 97 84

24
24 20 20

36. 8
36 36. 1 36

8.0 201.000

55

3.46

DANKE SCHOEN