CASE BASED DISCUSSION

Submitted for
A Partial Fulfillment of the Clinic Rotation Assignment in Internal Medicine Department
At Sultan Agung Islamic Hospital Semarang

Rizky Asvianto Aji

30101407313

Supervisor:

dr. M. Saugi Abduh, Sp.PD.KKV.FINASIM

DEPARTMENT OF INTERNAL MEDICINE

FACULTY OF MEDICINE SULTAN AGUNG ISLAMIC UNIVERSITY
SEMARANG
2020
I. IDENTITAS PASIEN
Nama : Ny. S

Umur : 43 tahun
Jenis kelamin : Female
Agama : Islam
Pekerjaan : housewife
No. RM : 01-41-xx-xx
Alamat : Semarang

Ruang dirawat : Naim

Tanggal pemeriksaan : -/09/2020

II. ANAMNESIS
Keluhan utama : Dyspneu

Riwayat Penyakit Sekarang :

The patient came to the polyclinic of Sultan Agung Islamic Hospital Semarang with
dyspsneu since 2 weeks ago post SC. Symptoms that occur independent of activity. Patients
usually sleep in the supine position because they feel tight, so they need more pillows while
sleeping to reduce dyspnoea.

Riwayat Penyakit Dahulu

Keluhan serupa : (-)
HT : (-)
DM : (-)
Alergi : (-)
 Riwayat Penyakit Keluarga
Keluhan serupa : (-)
HT : (-)
DM : (-)
Alergi : (-)

Riwayat Sosial Ekonomi

JKN-PBI

III. PEMERIKSAAN FISIK UMUM

Keadaan Umum : sakit sedang
Kesadaran : Compos mentis
GCS : 15

Vital Sign

◦ TD : 130/80 mmHg
◦ Nadi : 92x/menit
◦ RR : 20 x/menit
◦ Suhu : 36,9o C (aksila)
◦ SpO2 : 99%

Body Mass Index

◦ BB : 69 kg
◦ TB : 167 cm
◦ BMI : 24,7 ( Normoweight )

• Kulit : Pucat (-), ikterik (-)

• Mata : Pandangan kabur (-/-), Konjungtiva anemis(-/-)
• Telinga : bentuk normal, nyeri tarik auricular (-/-), nyeri tekan tragus (-/-),
sekret (-/-)
• Hidung : Sekret (-/-), deviasi (-/-)
• Mulut : Bibir tidak kering, gusi tidak berdarah, lidah kotor (-)
• Leher : Massa (-) , nyeri tekan (-), Pembesaran KGB (-)
IV. PEMERIKSAAN THORAKS - PULMO
PEMERIKSAAN
Inspeksi RR 36 kali/menit, simetris, pergerakan hemithorax dextra =
hemithorax sinistra, warna kulit sama dengan sekitar,
hiperpigmentasi (-), benjolan (-), tanda peradangan (-), retraksi
ICS (-), penggunaan otot-otot bantu pernapasan tambahan (-)
Palpasi Stem fremitus dextra = sinistra
Nyeri tekan (-)
Perkusi Redup
Auskultas suara dasar vesikuler (+/+), ronki (+/+), wheezing(-/-)
i

Interpretation : Lung oedem

V. PEMERIKSAAN THORAKS - JANTUNG

• Inspeksi : Ictus cordis tak tampak
• Palpasi : Ictus cordis teraba di ICS V linea mid clavicula sinistra, pulsus
parasternal (-), sternal lift (-), pulsus epigastrium (-)
• Perkusi :
Batas atas : ICS II linea sternalis sinistra
Batas pinggang : ICS III linea midclavicula sinistra
Batas kanan : ICS V linea sternalis dextra
Batas kiri : ICS VI 1cm dari linea midclavicula
• Auscultation
 Katup aorta : SD I-II murni, regular
 Katup tricuspid : SD I>II murni, regular
 Katup pulmonal : SD I-II murni, regular
 Katup mitral : SD I-II murni, regular
 Bising : (-)
Interpretasi : Cardiomegali
VI. PEMERIKSAAN FISIK ABDOMEN
PEMERIKSAAN
Inspeksi bentuk datar, warna kulit sama dengan sekitar, hiperpigmentasi (-), massa (-),
sikatrik (-), striae (-)
Auskultas bising usus (+) normal 18 x/menit
i
Perkusi timpani pada 4 kuadran
Hepar : dalam batas normal
Lien : dalam batas normal
Ginjal : nyeri ketok costovertebrae (-/-)
Palpasi teraba kenyal, defense muscular (-), nyeri tekan dan nyeri tekan dalam (-),
massa (-), nyeri tekan supra pubis (-) Hepar dalam batas normal, tepi lancip,
permukaan rata, konsistensi kenyal, nyeri tekan (-).
Murphy sign (-). Lien dalam batas normal. Ginjal dalam batas normal

Interpretation : Normal
VII. PEMERIKSAAN EKSTREMITAS
Atas Bawah
Edema -/- -/-
Akral dingin -/- -/-
Capillary refill <2”/<2” <2”/<2”
Kesemutan / kebas -/- -/-

Interpretation : Normal

VIII. PEMERIKSAAN LABORATORIUM

TEST RESULT NORMAL RESULT

Hematology
Hb 11,7 13.2-17.3
Hematocrit 35.8 33-45
Leukocyte 10.04 3.80-10.6
Eritrocyte 4.5 4,4 – 5,9
Trombocyte 440 150-440
Eosinofil 3.6 1-3
Basofil 0,7 0-1
Neutrofil 66,9 50-70
Limfosit 20.5 25-40
Monosit 5.9 2-8
IG% 0,3
KIMIA KLINIK
HDL 58 28-63 mg/dL
LDL 138 60-100 mg/dL
Kolesterol total 232 <200 mg/dL
TG 78 <100 mg/dL
Asam urat 6,3 3,5-7,2 mg/dL
GDS 210 (H) <200 mg/dL
Ureum 50 10-50
Creatinin 1.1 0,70 – 1,30
Natrium 140.1 135-147
Kalium 3,71 3.5-5
Chloride 102,3 95-105
CRP kuantitatif 0.1 <=3
HBsAg Non reaktif

Interpretation : Hiperurisemia, Dislipidemia

IX. EKG
• Irama : Sinus
• Regularitas : Regular
• Frekuensi : 122 x/menit
• Gelombang P : Amplitudo = 0,2 mV, Durasi = 0,12 s ( Normal )
• Interval PR : 4 x 0,04 s = 0,16 s ( Normal )
• Kompleks QRS
- Interval : 3 x 0,04 s = 0,12 s ( normal )
- Axis : Lead I (+) dan avf (-)  LAD
- Zona transisi : -
- Q patologis : -
- LVH :-
- RVH :-
• Segmen ST
- ST Elevasi :-
- ST Depresi : -
Gelombang T
 - T Inverted :-
Kesan : Normo Sinus Rhytm, LAD

X. PEMERIKSAAN X-FOTO THORAKS

• Cor : Tampak membesar

• Pulmo : coracan bronkovaskuler tak meningkat meningkat

• Difragma dan sinus kostrofrenicus tak tampak kelainan

 Kesan :

• Kardiomegali

• Oedem pulmo

XI. ECHOCARDIOGRAPHY
Dimensi ruang jantung :membesar di LA
dinding LV : menebal di IVS dan PW
Wall Motion : Global Hipokinetik
Katup Jantung : MR Moderate
Fungsi LV sistolik menurun EF 26%
Fungsi RV Sistolik Baik TAPSE 22 mm
Fungsi LV Diastolik baik E/A > 1
Kesan:
Global Hipokinetik
Function of LV sistolik decrease
Function of RV Sistolik normal,
Dilatation of LA, LV
LVH consentric and excentric
MR Moderate
XII. ABNORMALITAS DATA
Anamnesis:

1. Dypsneu

Pemeriksaan Fisik

2. Tachycardia

3. Tachypneu

4. Dullness percussion in both chest

5. Ronchi at basal chest

6. Cardiomegaly

Pemeriksaan Penunjang

7. Cholesterol

8. LDL Cholesterol Direct

9. Hyperuricemia

10. LAD

11. Lung edem

12. Cardiomegaly

13. Function of LV sistolik decrease

14. LVH consentric and excentric

15. MR Moderate
XIII. PROBLEM LIST
1. CHF
 Dypsneu
 Tachycardia
 Tachypneu
 Dullness percussion in both chest
 Ronchi at basal chest
 Cardiomegaly
 LAD
 Lung edem
 Cardiomegaly
 Function of LV sistolik decrease
 LVH consentric and excentric
2. VHD
 MR Moderate
3. Hiperurisemia
 Hyperuricemia
4. Dislipidemia
 Cholesterol
 LDL Cholesterol Direct

XIV. DISCUSSION
1. CHF NYHA IV
 Assessment
- Etiology : kardiomiopaty post partum
 Initial Plan of Diagnosis
- BNP dan Pro BNP
 Initial Plan of Therapy
Pharmacology
• B-Blocker  Bisoprolol 2,5 mg 1x1
 • ACE inhibitor  captopril
• Spironolacton 25 mg 1x1
 Initial Plan of Monitoring
Vital sign, congestive sign ,ECG, echocardiografy
 Initial Plan of Education :
• Bed Rest/Restriction of physical activity
• Reducing Emotional stress
• Routine consumption drugs
• Fluid restriction (1,5 L-2L/day)

2. VHD
 Assessment
• Anatomy : Mitral Regurgitation
 Initial Plan of Diagnosis :
Transesophageal ecocardiography
 Initial Plan of Therapy
Non Farmacology
 Initial Plan of Monitoring
- Vital sign
- ECHO ulang saat kondisi sudah stabil
 Initial Plan of Education :
• Reduced activity
• Education about disease
3. HIPERURISEMIA
 Assessmen

 Initial Plan of Diagnosis :

-
 Initial Plan of Therapy
• Reduce the diuretic dose
• Allopurinol 300mg 1x1
 Initial Plan of Monitoring
- Level of uric acid
 Initial Plan of Education :
• Avoid meats high in purine contains
• Avoid sweetened soda beverage
• Do Excercise
• Stay well hydrated

4. DISLIPIDEMIA
 Assessmen
• Complication : Fatty Liver, PJK, Sindroma metabolic
 Initial Plan of Diagnosis :
-
 Initial Plan of Therapy
Pharmacology :
• Atorvastatin 20 mg
Non pharmacology
• Low cholesterol intake
• Do mild exercise
 Initial Plan of Monitoring : total cholesterol, HDL, LDL, trigliserid
 Initial Plan of Education :
• Eat high fiber diet and low fat
• Reduce fatty food, soda and junk food
• Low exercise regularly
• Edukasi : jangan hamil lagi