Keterampilan

Diagnosis & Terapi

Pasien dengan
Keluhan

Nyeri Dada
C. Singgih Wahono
Lab/ SMF Ilmu Penyakit Dalam RSSA/
FK UB

Dok, dada saya sakit

sekali.... Kenapa ya
dok?
Ada yang bisa saya
bantu pak?

Nyeri Dada
Merupakan tantangan dalam mendiagnosisnya
Diagnosis banding: organ/ struktur thorax dan
abdomen
Dampak prognostik: ringan sampai berat
(mengancam jiwa)
Bila gagal mendiagnosis kondisi yang serius (ACS,
aortic dissection, tension pneumothorax,
pulmonary embolism): menyebabkan komplikasi
serius.
Dapat menyebabkan over diagnosis pada kondisi
ringan.

Clinical Diagnostic
Reasoning

Keluhan

Px

Clinical
Therapeutic
Reasoning

Diagnosis

Clinical Reasoning

Terapi

Clinical Diagnostic Reasoning

Knowledge

Patient story
Data acquisition
Problem representation

Context
Hypothesis
Illness script

Diagnosis

Experience

Dok, dada saya sakit

sekali.... Kenapa ya
dok?
Ada yang bisa saya
bantu pak?

PATIENT STORY

Data Acquisition
Based on knowledge, experience, and other
important context
Subjective
Elements:
data
Objective
History,
data
Findings on physical examination,
Results of laboratory testing and
imaging studies

Pain Guided (OPQRST)

Onset of problem
Provocation/Palliative
Quality
Region/Radiation
Severity
Time

History Taking
Laki-laki, 60 tahun datang ke UGD RSSA
Chief complaint: nyeri dada
History of present illness: nyeri dada kiri
timbul 1 jam sebelum ke RS, terasa seperti
ditekan benda berat, menjalar ke lengan kiri,
dan berlangsung sampai sekarang . Nyeri
timbul saat pasien menonton pertandingan
bola piala dunia. Nyeri tidak berkurang
dengan istirahat.

 Nyeri dada disertai rasa seperti susah bernapas.

3 hari ini penderita mengeluh perut terasa tidak
enak dan agak mual terutama setelah makan.
Menderita DM dan hipertensi sejak 10 tahun
yang lalu dengan obat metformin dan captopril.
Past medical history: operasi usus buntu 10 tahun
yang lalu

 Family and social history: bapak dan ibu

penderita juga mengalami DM dan hipertensi,
dan keduanya meninggal mendadak. Pasien
adalah pensiunan dan sekarang jarang
beraktivitas fisik.
Review of system: penglihatan dan
pendengaran berkurang.

Pemeriksaan fisik
Kesan umum: tampak gelisah dan agak kesakitan
Gizi: kesan overweight
TD: 140/100 mmHg, nadi: 102 x/menit-regularpengisian cukup, RR: 24 x/menit, t ax: 36,5C
Thoraks: tidak ada nyeri pada penekanan dinding
dada
-Cor: HR 102 x/menit-regular, tidak ada bising
-Pulmo: tidak ada kelainan
Abd: cembung, supel, BU + normal
Extremitas: tidak ada kelainan, akral hangat

Problem Representation
Nyeri dada tipikal, awitan akut, berlangsung
kurang lebih 60 menit, timbul saat aktivitas
fisik ringan, yang terjadi pada seorang lakilaki usia 60 tahun, yang menderita Diabetes
mellitus dan hipertensi.

Illness Script
The way the clinical experience and knowledge
stored in memory
Storage Strategy of Experts
Problem representation trigger clinical memory,
permitting the related knowledge (illness script) to
become accessible for reasoning

Illness Script: Key To Pattern

Recognition
Generated by reading and by experience
Has a predictable structure:
predisposing conditions,
pathophysiological insult,
clinical consequences

Another structure:
epidemiology,
temporal pattern,
syndrome statement

Content: those elements which distinguish among like diseases

Illness Script: Gout

Illness Script
Syndrome: Acute Chest Pain
Disease

Epidemiology
Temporal Course
Syndrome
Description

StableAngina
pectoris

Acute
coronary
syndrome

Spontaneous
Pneumothorax

Gastroesophage
al reflux disease

EPIDEMIOLOGY
More prominent in males between the ages of
40 and 65 yr; no predominant sex after age 65
yr
Women experience more lethal and severe
first acute MIs than men regardless of
comorbidity, previous angina, or age
At least one fourth of all MIs are clinically
unrecognized

Clinical presentation:
Crushing substernal chest pain usually lasting
.30 min.
Pain is unrelieved by rest or sublingual
nitroglycerin or is rapidly recurring.
Pain radiates to the left or right arm,
neck, jaw, back, shoulders, or abdomen and is
not pleuritic in character.
Pain may be associated with dyspnea,
diaphoresis, nausea, or vomiting.

Hasil EKG

Diagnosis
Myocard infarct with ST elevation (STEMI)

Planning diagnosis
STEMI: cardiac enzym
Pneumothorax: Foto thorax
Gastroesophageal disease: endoscopy?

Treatment

NONPHARMACOLOGIC THERAPY
Limit patients activity: bed rest for the initial 12
to 24 hr; if the patient remains stable,
gradually increase activity.
Diet: nothing by mouth until stable, then a
low-salt and a low-cholesterol diet.
Patient education to decrease the risk of
subsequent cardiac events (proper diet,
smoking cessation, regular exercise) should be
initiated when the patient is medically stable
PHARMACOLOGIC TREATMENT: see Clinical
pathway

PHARMACOLOGIC TREATMENT
STEMI dengan onset chest pain < 3 jam dilakukan
terapi reperfusi dengan:
Streptokinase 1.5 juta U/100cc D5/60 menit bila onset
chest pain < 3 jam
Enoxaparin 2x0.6cc (sc) untuk 5 hari, atau Fondaparinux
1x2.5mg (sc) untuk 5 hari, atau Heparin UFH loading 5000u
iv dilanjutkan rumatan 1000/jam s/d 48 jam dengan target
aPTT 1.5-2 kali kontrol, periksa tiap 6 jam.

STEMI dengan onset chest pain > 3 jam dilakukan

terapi reperfusi dengan:
Dilakukan Primary Coronary Intervention

PHARMACOLOGIC TREATMENT
Semua pasien yang dilakukan terapi reperfusi diberikan:
Clopidogrel loading dose 600mg dilanjutkan maintenance 1x75
mg
Asam Asetil Salisilat loading dose 300 mg dilanjutkan
maintenance 1x80-100 mg
Statin simvastatin atau atorvaststin 20-40mg
ACE inhibitor captopril 3x25 mg, lisinopril 1x5-10 mg, ramipril
1x2.5-5mg atau
ARB : valsartan 1x80-160mg, telmisartan 1x80-160 mg,
irbesartan 1x150-300mg
Beta Blocker : bisoprolol 1x2.5mg-5mg, carvedilol 1x12.5mg25mg, propanolol 2x80-160mg
Nitrat iv 1-5mg atau peroral 3x5-80mg

Problem Oriented Medical Report

(POMR)
Cue and
clue

Problem
list

Initial Dx
And
Differenti
al
diagnosis

Planning
Dx

PlanningT
x

Planning
Monitorin
g

Planning
Education