CBD

CASE BASE DISCUSSION

MOHAMAD REZA HENDRATMOKO
30101206681
Advisor : dr. H. M. SAUGI ABDUH, Sp.PD., KKV, FINASIM

Department of Internal Medicine

Medical School of Sultan Agung Islamic University
2016
PATIENTS IDENTITY
Name : Mrs. S
Age : 56 y.o.
Gender : Female
Religion : Moslem
Job : Seller
Address : Banjardowo RT 9/4 Genuk
Semarang
MR number : 01-26-47-51
Room : Baitul Izzah 1 411.2
Entry date : August 11th, 2016
Date out : August 15th, 2016
HISTORY TAKING
Main Chest
Proble Pain
m
Patient came into the emergency
department in Islamic Hospital of Sultan
History Agung Semarang, complained about her
of chest pain. Its started at 8 August 2016. The
Present
Illness pain localized on substernal and radiate to
her back. At that day, the pain often come
and worsening when do an activity. Duration
of the pain + 30 minutes. She felt better
when she took a rest. She also complained
epigastrial pain, nausea and vomitus.
HISTORY OF ILLNESS
HISTORY OF PREVIOUS ILLNESS SOSIO-ECONOMIC
Hypertension history (+) HISTORY :
DM history (-) Hospital cost certified
Asthma history (-) by
Alergy history (+) SELF PAYMENT
SMOKING (-)

FAMILYS HISTORY OF DISEASE

Hypertension history (+)

DM history (-)

Asthma history (-)

SISTEMIC
ANAMNESIS
Chief Complains : Chest pain

Onset : 1 days ago

Location : Substernal

Chronology : Patient felt this pain after sell at store

Quality and Quantity : The pain worsening when do activity.

The pain spread to her back. The pain attack come more
than one time, each attack worsening and longer

Modification factor : Better when she took a rest

Comorbid complains : Epigastric pain, nausea, vomitus

 PHYSICAL
General

Skin
EXAMINATION
: composmentis Throat :painswallow(-), hoarseness(-),
odinifagia(-)
:itching(-),jaundice(-),pale(-) Neck : enlargement ofthe gland(-)
Chest :cough(-),sputum(-),blood(-)
Head :headache(-)
Cardiac :chest pain(+),palpitations(-)
Eyes :blurredvision(-),red
Digestive :abdominal pain (+),nausea(+),
eyes(-), ictericsclera(-/-)
vomiting(+)
Ears :hearingloss(-),ring(-), Musculoskeletal :weak(-),rigid(-),back pain (-)
discharge(-) Extremity : oedem extremity (-)

Nose :nosebleed(-),discharge(-)

Mouth :cyanosis(-), thrush(-),

bleeding gums(-)
GENERAL STATUS
BMI (Body Mass Indeks)
BMI (Body Mass Indeks)
weight : 67 BMI= (1,67 x 1,67) : 67 = 24,0
weight : 67 BMI= (1,67 x 1,67) : 67 = 24,0
High : 160
High : 160 Intepretation
:
Intepretation :
Normoweight
Normoweight
General : Chest pain
General : Chest pain
Awareness : Fully Aware / Compos Mentis (GCS=15)
Awareness : Fully Aware / Compos Mentis (GCS=15)
Vital Sign
Vital Sign
Blood Pressure : 230/130 mmHg
Blood Pressure : 230/130 mmHg
Heart rate : 80 x/minute
Heart rate : 80 x/minute
Breath Frequency : 24 x/minute
Breath Frequency : 24 x/minute
Temp : 36,0oC Intepretation : Crisis
Temp : 36,0oC Intepretation : Crisis
Hypertension
Hypertension
GENERAL STATUS
Head : Mesocephal, alopesia (-)
Head : Mesocephal, alopesia (-)
Eyes : Anemic Conjuntiva(-/-),Icteric sclera(-/-)
Eyes : Anemic Conjuntiva(-/-),Icteric sclera(-/-)
Nose : symmetric, secret (-), Nostril Breath (-)
Nose : symmetric, secret (-), Nostril Breath (-)
Ears : Normal Shape, discharge (-/-)
Ears : Normal Shape, discharge (-/-)
Esophagus : Hyperemic (-), pain devour (-)
Esophagus : Hyperemic (-), pain devour (-)
Mouth : Cyanosis (-), dry lips (-),
Mouth : Cyanosis (-), dry lips (-),
Neck : Trakhea deviation (-), Lymph Hypertropy (-)
Neck : Trakhea deviation (-), Lymph Hypertropy (-)
Extremity : Oedem of lower extremity / upper extremity
Extremity : Oedem of lower extremity / upper extremity
(-) / (-)
(-) / (-)
Intepretation : Normal
Intepretation : Normal
LUNG
EXAMINATION
INSPEKSI ANTERIOR POSTERIOR
Static RR : 24x/min, Hyper pigment (-), spider RR : 24x/min, Hyper pigment
nevi (-),spider nevi (-), Hemithoraks
(-), atrophy Pectoral Muscle (-), D=S,
Hemithoraks D=S, ICS Normal, Diameter ICS Normal, Diameter AP < LL
AP < LL
Dynamic Up and down of hemitoraks D=S, Up and down of hemitoraks D=S,
abdominothorakal breathing, (-), muscle abdominothorakal breathing (-),
retraction of breathing (-), muscle retraction of breathing(-),
retraction ICS (-) retraction ICS (-)
Palpation Palpable pain(-), tumor (-), Arcus costae Palpable pain (-), tumor (-), Arcus
angle < 900, enlargement of ICS (-), Stem costae angle < 900, enlargement of
fremitus D=S ICS (-), Stem fremitus D=S

Percution Sonor Sonor

Auskultati Vesicular (+), Whezzing (-), Ronchi (-) Vesicular (+), Whezzing (-),
Intepretation :
on Ronchi (-) Intepretation :
NORMAL
NORMAL
CARDIAC
EXAMINATION
Inspection : Ictus cordis isnt seen.
Inspection : Ictus cordis isnt seen.

Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-),

Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-),
sternal lift (-).
sternal lift (-).

Percussion : dull sound

Percussion : dull sound
Upper borderline of heart : ICS II left sternal line
Upper borderline of heart : ICS II left sternal line
Waist of heart : ICS III left parastern line
Waist of heart : ICS III left parastern line
Lower right borderline of heart : ICS V right sternal line
Lower right borderline of heart : ICS V right sternal line
Lower left borderline of heart : ICS V, 2 cm lateral from left mid
Lower left borderline of heart : ICS V, 2 cm lateral from left mid
clavicle line
clavicle line
CARDIAC...CONT
Auscultation
Auscultation
Aortal valve : S1 & S2 standard, additional sound (-)
Aortal valve : S1 & S2 standard, additional sound (-)
Pulmonary valve: S1 & S2 standard, additional sound (-)
Pulmonary valve: S1 & S2 standard, additional sound (-)

Tricuspid valve : S1 & S2 standard, additional sound (-)

Tricuspid valve : S1 & S2 standard, additional sound (-)

Mitral valve : S1 & S2 standard, additional sound (-)

Mitral valve : S1 & S2 standard, additional sound (-)

Intepretation : NORMAL
Intepretation : NORMAL
 ABDOMEN
EXAMINATION
Inspection : symetric, sycatric(-), striae(-),enlargement of vena (-),
Inspection : symetric, sycatric(-), striae(-),enlargement of vena (-),
caputmedusa (-).
caputmedusa (-).
Auscultation : peristaltic (+)
Auscultation : peristaltic (+)
Palpation :
Palpation :
Superfisial : tight (-), mass (-), epigastrial pain (+)
Superfisial : tight (-), mass (-), epigastrial pain (+)
Deep : abdominal pain (-), liver, kidney, and spleen werent
Deep : abdominal pain (-), liver, kidney, and spleen werent
palpable, Murphys sign (-)
palpable, Murphys sign (-)
Percussion : tympani, side of deaf (-), shifting dullness (-)
Percussion : tympani, side of deaf (-), shifting dullness (-)
Liver : deaf(+), right liver span 11 cm, left liver span 6 cm
Liver : deaf(+), right liver span 11 cm, left liver span 6 cm
Spleen : Throbe space percussion (+) tympani
Spleen : Throbe space percussion (+) tympani
Intepretation: :
Intepretation
abdominal pain
abdominal pain
EXTREMITY
EXAMINATION
EkstremitasSuperior Inferior
EkstremitasSuperior Inferior
Oedema -/- -/-
Oedema -/- -/-
Cold -/- -/-
Cold -/- -/-
Jaundice -/- -/-
Jaundice -/- -/-
LAB. EXAMINATION
Examination Result Examination Result
Cholesterol 203 mg/dl Hemoglobin 12,9 g/dl
Trigliserid 71 mg/dl Hematokrit 38,2 %
HDL 46 mg/dl Leukosit 18,04 ribu/ uL
LDL 132 mg/dl Trombosit 332 ribu/ uL
Uric acid 5,4 mg/dl Troponin I 0,11 ug/L
Ultra
Ureum 18 mg/dl
Creatinin 0,58 mg/dl Intepretation :
Intepretation :
Hipercolesterol
Hipercolesterol
LDL
LDL
Leukositosis
Leukositosis
Elevation of cardiac marker
Elevation of cardiac marker
SERIAL ECG
11/8/16
ECG 11/8/2016
IRAMA : Sinus rhytm
IRAMA : Sinus rhytm
REGULARITAS : Regular
REGULARITAS : Regular
FREKUENSI : 93x/menit
FREKUENSI : 93x/menit
AXIS : L1 (+) AVF (-) -> LAD
AXIS : L1 (+) AVF (-) -> LAD
GELOMBANG P : 2 x 0,04 = 0,08 s
GELOMBANG P : 2 x 0,04 = 0,08 s
PR INTERVAL : 4 x 0,04 = 0,16 s
PR INTERVAL : 4 x 0,04 = 0,16 s
QRS COMPLEX : 0,08 s
QRS COMPLEX : 0,08 s
ST SEGMEN : ST depression (L II, aVF, V4, V5)
ST SEGMEN : ST depression (L II, aVF, V4, V5)
GELOMBANG T : T prekordial : <10 mV T ekstremitas : <5 mV
GELOMBANG T : T prekordial : <10 mV T ekstremitas : <5 mV
t inverted (V1)
t inverted (V1)
ZONA TRANSISI : V4 Intepretation :
ZONA TRANSISI : V4 Intepretation :
1. LAD
1. LAD
2. Ischemic on inferior and
2. Ischemic on inferior and
anterior
12/8/16
ECG 12/8/2016
IRAMA : Sinus rhytm
IRAMA : Sinus rhytm
REGULARITAS : Regular
REGULARITAS : Regular
FREKUENSI : 93x/menit
FREKUENSI : 93x/menit
AXIS : L1 (+) AVF (-) -> LAD
AXIS : L1 (+) AVF (-) -> LAD
GELOMBANG P : 2 x 0,04 = 0,08 s
GELOMBANG P : 2 x 0,04 = 0,08 s
PR INTERVAL : 4 x 0,04 = 0,16 s
PR INTERVAL : 4 x 0,04 = 0,16 s
QRS COMPLEX : 0,08 s
QRS COMPLEX : 0,08 s
ST SEGMEN : ST depression (L II, aVF)
ST SEGMEN : ST depression (L II, aVF)
GELOMBANG T : T prekordial : <10 mV T ekstremitas : <5 mV
GELOMBANG T : T prekordial : <10 mV T ekstremitas : <5 mV
T inverted (V1, V3)
T inverted (V1, V3)
ZONA TRANSISI : V4 Intepretation :
ZONA TRANSISI : V4 Intepretation :
1. LAD
1. LAD
2. Ischemic on inferior and
2. Ischemic on inferior and
anterior
anterior
13/8/16
ECG 13/8/2016
IRAMA : Sinus rhytm
IRAMA : Sinus rhytm
REGULARITAS : Regular
REGULARITAS : Regular
FREKUENSI : 93x/menit
FREKUENSI : 93x/menit
AXIS : L1 (+) AVF (-) -> LAD
AXIS : L1 (+) AVF (-) -> LAD
GELOMBANG P : 2 x 0,04 = 0,08 s
GELOMBANG P : 2 x 0,04 = 0,08 s
PR INTERVAL : 4 x 0,04 = 0,16 s
PR INTERVAL : 4 x 0,04 = 0,16 s
QRS COMPLEX : 0,08 s
QRS COMPLEX : 0,08 s
ST SEGMEN : ST depression (L II, aVF)
ST SEGMEN : ST depression (L II, aVF)
GELOMBANG T : T prekordial : <10 mV T ekstremitas : <5 mV
GELOMBANG T : T prekordial : <10 mV T ekstremitas : <5 mV
T inverted (V1, V3)
T inverted (V1, V3)
ZONA TRANSISI : V4 Intepretation :
ZONA TRANSISI : V4 Intepretation :
1. LAD
1. LAD
2. Ischemic on inferior and
2. Ischemic on inferior and
anterior
anterior
14/8/16
ECG 14/8/2016
IRAMA : Sinus rhytm
IRAMA : Sinus rhytm
REGULARITAS : Regular
REGULARITAS : Regular
FREKUENSI : 93x/menit
FREKUENSI : 93x/menit
AXIS : LAD
AXIS : LAD
GELOMBANG P : 2 x 0,04 = 0,08 s
GELOMBANG P : 2 x 0,04 = 0,08 s
PR INTERVAL : 4 x 0,04 = 0,16 s
PR INTERVAL : 4 x 0,04 = 0,16 s
QRS COMPLEX : 0,08 s
QRS COMPLEX : 0,08 s
ST SEGMEN : isoelektris
ST SEGMEN : isoelektris
GELOMBANG T : T prekordial : <10 mV T ekstremitas : <5 mV
GELOMBANG T : T prekordial : <10 mV T ekstremitas : <5 mV
ZONA TRANSISI : V3
ZONA TRANSISI : V3

Intepretation : NORMAL
Intepretation : NORMAL
 ECG SERIAL RESULT
ECG RESULT
DATE ST T Enlarge INTERPRETATION
depressio inverte Axis ment
n d
11/8/2016 L II, aVF, V1, V2 LI (+), N SNR, LAD, Ischemic on
V4, V5 AVF (-) Inferior+anterior
12/8/2016 L II, aVF V1, V3 LI (+), N SNR, LAD, Ischemic on
AVF (-) Inferior+anterior
13/8/2016 LII, aVF V1, V3 LI (+), N SNR, LAD, Ischemic on
AVF (-) inferior, non spesific
anterior
14/8/2016 isoelektris N LI (+), N SNR, NAD
AVF (+)
Abnormal Data ECG :
7. LAD
8. ST depression
9. T inverted
Physical
Examination
History Taking Lab
5. Epigastrial
1. Chest pain, Hematology
pain
2.Stomach pain, 3. 10. Total kolesterol
6.High blood
Nausea, 4.Vomitus 11. LDL
pressure :
12. Leukositosis
230/130
13. Elevation of
Cardiac marker
 PROBLEMLIST
PROBLEM LIST

1 2
SKA CRISIS
SKA CRISIS
(1, 8, 9, 13) HYPERTENSION
(1, 8, 9, 13) HYPERTENSION
(6)
(6)

3 4
DISLIPIDEMI DISPEPSIA
DISLIPIDEMI DISPEPSIA
A (2, 3, 4, 5)
A (2, 3, 4, 5)
(10, 11)
(10, 11)
1.
ska
Ass: UAP Pharmacology

NSTEMI O2 nasal canul 4L/minute

IP Dx : Angiografi koroner Bisoprolol 2,5 mg 1x1

IP Tx : ISDN subl. 5 mg 3x1 prn

Non Pharmacology Aspillet 80 mg 1x1

Low cholesterol intake CPG 75 mg 1x1

Reduce activity truvast (atorvastatin) 0-0-1

High fiber diet Heparin

 Ip. Mx : Vital sign, ECG serial, echocardiography, APTT

Ip. EX :

Bed Rest/Restriction of physical activity

Reduce fatty food

Control blood pressure

Reducing Emotional stress

Routine consumption drugs

Consumption of antioksidan (green tea)

Avoid smoking

Do sport regularly, 4 times each week, duration: 30-60

minutes
 1. SKOR TIMI
Parameter Skor Hasil
Usia >65 th 1 0
Lebih dari 3 FR 1 0
Angiografi stenosis 1 0
>50%
Penggunaan aspirin 7 1 1
hari terakhir
2 Episode/ lebih nyeri 1 1
dada saat istirahat
Deviasi T >1mm saat 1 1
tiba
Elevasi cardiac 1 1
marker
TOTAL 4
INTERPRETASI MENENGAH
2. SKOR GRACE

PARAMETER SKOR
Usia 36
HR 7
Sistol 0
Kreatinin 5
KILLIP 0
Cardiac arrest 0
Peningkatan cardiac marker 15
Deviasi segmen ST 30
TOTAL 93
INTERPRETASI RESIKO RENDAH (<1%)
4. SKOR CRUSADE
DM SKOR
Hematokrit awal 2
Klirens kreatinin 7
HR 1
Jenis kelamin 8
Tanda gagal jantung 0
saat datang
Riwayat penyakit 0
vaskuler sebelumnya
DM 0
Tekana dararh sistol 5
TOTAL 23
INTERPRETASI RENDAH (5,5%)
 HAS BLED SCORE
PARAMETER SKOR
Hypertension history +1
Renal disease 0
Liver disease 0
Stroke history 0
Prior major bleeding or 0
predisposition to bleeding
Labile INR 0
Age >65 0
Medication usage predisposing to 0
bleeding
Alcohol or drug history 0
TOTAL +1
INTERPRETATION LOW RISK
Framingham score to assess risk
to become IHD
PARAMETER SCORE
Usia 8
Kolesterol total 4
Perokok/bukan 0
HDL 1
Tekanan darah 4
TOTAL SCORE 17
% FAKTOR RESIKO dalam 10 5%
tahun menjadi PJK
INTERPRETASI MODERAT
Skala resiko Framingham

Resiko tinggi : pasien dengan PJK , score > 20%

Resiko tinggi moderat : mempunyai 2 FR selain LDL, score 10% -
20%
Resiko moderat : mempunyai 2 faktor resiko selain LDL, score <
10%
Resiko rendah : mempunyai 0-1 faktor resiko selain LDL
Stratifikasi resiko
Rendah : pasien tidak memiliki kelainan angina sebelumnya dan
sudah tidak ada serangan angina, tidak memakai obat anti
angina dan ECG normal, enzim jantung tidak meningkat,
biasanya masih muda
Sedang : angina baru, makin berat, angina waktu istirahat, tidak
ada perub segmen ST, enzim jantung tidak meningkat
Tinggi : angina istirahat, angina berlangsung lama atau post
infark, sebelumnya sudah mendapat terapi yang intensif, usia
lanjut, perubahan segmen ST, kenaikan enzim jantung,
hemodinamik tidak stabil
2. CRISIS
HYPERTENSION
Ass : Emergency hypertension

Urgency hypertension
Ip Dx : Funduscopi, X foto thorax, USG abdomen, brain ct scan,
arteriografi, echocardiography, protein urine
Ip Tx :
Non Pharmacology :

Bed rest

Low salt intake

Low fat and high fiber diet

Pharmacology : inj. Diltiazem 0,2 mg/kgBB

 Ip. Mx : Blood pressure, neurological status (GCS), cardiopulmonary
status, body fluid volume assesment
Ip.Ex :
Diet low salt

Consumption vegetable, fruit

Routine consumption drugs

3.
DISLIPIDEMIA
Ass: -

IP Dx : -

IP Tx :

Pharmacology :

Atorvastatin 20 mg 0-0-1

RESUVASTATATIN

Non pharmacology

Daily dietary consumption of fruits and vegetables

Exercise 60 minutes with aerobic and resistance

training

Achieve ideal body mass index and body weight

 Ip.Mx : total cholesterol, HDL, LDL, trigliserid

Ip.Ex :

Eat high fiber diet and low fat

Reduce fatty food, soda and junk food

Low exercise regularly

Dislipidemia Score
(ESC)
Age : 56
Women
Non smoker
Sistol : 180
Kolesterol total : 203
SCORE = 3
Risk : Moderate risk to CVD
Therapy of dislipidemia
(AHA)
Statin Therapy
4.
DISPEPSI
A
Ass: Functional dispepsia (Post prandial Non pharmacology

distress syndrome, epigastric pain syndrome) Reduce fiber food, spicy

Organic dispepsia (duodenal ulcer, gastric and acid food

ulcer, gastritis) Avoid alcohol, soda

IP Dx : Kontras OMD, endoskopi, urea breath Reduce emotional stress

test, PPI Test

IP Tx :

Pharmacology

Omeprazole 20 mg 2x1

Ondansetron 3x4mg

Sukralfat syr 3x1 C

 Ip.Mx : Dehidration state, general examination (ikterik,

odinofagia, vomitus, nausea, limfadenopathy,

hematemesis/melena without etiology), Hb

Ip.Ex :

Reduce eat spicy, acid and fatty food

Avoid alcohol, soda

Reduce emotional stress

Increase diet frequent with small portion

 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