CASE BASED DISCUSSION

21 years old men with dispneu

Marynda Rahmadianisya Advisor :

30101306987 dr. M Saugi Abduh, Sp.PD, KKV, FINASIM
 PATIENT’S IDENTITY
 Name : Mr. TY
 Age : 21 years old
 Sex : Male
 Religion : Moslem
 Job : Worker
 Address : Sendangrejo RT 02/03 Bojonegoro, Blora
 Medical Record Number : 01.33.61.91
 Room : Baitul Izzah 1
 Entry Date : 7th December 2017
 Date Out : 16th December 2017
 HISTORY TAKING
MAIN PROBLEM
Dispneu

HISTORY OF PRESENT ILLNESS

Patients came to polyclinic of Sultan Agung Islamic Hospital with complain of
dispneu. Patients feel the dispneu since 1 month ago. 7 days before he came to
polyclinic, he had a sudden dispneu while he works. Patients described his
dispneu heaviness. Before transferred to polyclinic he had been hospitalized for
7 days in the regional hospital of Blora. Patients also complained chest pain
and cough.
 SISTEMIC ANAMNESIS
Onset : 1 month ago
Location : Pain at chest irradiating to interscapular region
Chronology : Patients had a sudden dispneu while he works
Quality : Patients described his dispneu as heaviness
Quantity : Dispneu felt continously
Modifying factors : Patients feels dispneu mostly when he working
some activities
Other complaints : Patients also complained chest pain and cough
 HISTORY OF ILLNESS
History of
previous illness
• Same symptom/illness (+)
• Hypertension history (-)
• DM history (-)
• Asthma history (-)
• Alergy history (-)
• Cardiac Disease (-)
• Drug allergy (-)
Family’s history of
disease
• Hypertension history (-)
• DM history (-)
• Asthma and alergy history (-)
Sosio-Economic
History
• Hospital cost certified by
JKN PBI
 GENERAL PHYSICAL EXAMINATION
•BMI
Weight : 51 kg Interpretation :
High : 167 cm Normoweight
BMI : 18.34
• General : weakness
• Awareness : composmentis
• Vital sign :
BP = 110/70 mmHg
Pulse = 80 x/menit Interpretation :
RR = 24 x/menit Normal
T = 37.5C
 Head : Mesocephal, alopesia (-)

Eyes : Anemic conjuntiva(-/-),

Icteric sclera(-/-) Nose : Symmetric, secret (-), Nostril Breath (-)

Mouth : Cyanosis (-), dry lips (-), snoring (-)

Ears : Normal shape, discharge (-/-)

Neck : Trakhea deviation (-),

Lymph Hypertropy (-)

Extremity : Oedem of lower extremity

(-), Oedem of upper extremity (-)
 CHEST EXAMINATION - LUNG
INSPEKSI ANTERIOR POSTERIOR

Static RR : 24x/min, Hyperpigment (-), spider nevi RR : 24x/min, Hyperpigment

(-), atrophy Pectoral Muscle (-), Hemithoraks D=S, ICS (-),spider nevi (-), Hemithoraks D=S,
Normal, Diameter AP < LL ICS Normal, Diameter AP < LL

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

Palpation Palpable pain(-), tumor (-), enlargement of ICS (-), Palpable pain (-), tumor (-), enlargement of ICS (-),
Stem fremitus decrease Stem fremitus decrease

Percution dullness (+) dullness (+)

Auskultation Vesicular (+) decrease , Whezzing (-), Ronchi (-) Vesicular (+) decrease, Whezzing (-),
Ronchi (-)
 THORAX - COR
DATE : 10th December 2017

INSPECTION
Ictus cordis -
PALPATION
Ictus cordis palpable at ICS VI 3 cm medial from linea mid
clavicula sinistra

Thrill -
Pulsus epigastrium -

Pulsus parasternal -

Sternal lift -
 PERCUTION
Upper borderline ICS II linea sternalis sinistra

Waist ICS III linea parasternalis sinistra

Lower right borderline ICS V linea sternalis dextra

Lower left borderline ICS V 2 cm medial from linea mid clavicula sinistra

AUSCULTATION
Aorta valve S1 & S2 standart
Additional sound (-)
Pulmonal valve S1 & S2 standart
Additional sound (-)
Trikuspidal valve S1 & S2 standart
Additional sound (-)
Mitral valve S1 & S2 standart
Additional sound (-)
INTERPRETATION Normal
 ABDOMEN
DATE : 10th December 2017

EXAMINATION RESULTS

Inspection Simetrics
Sycatric (-)
Striae (-)
Enlargement of vena (-)
Caput medusa (-)
Spider nevi (-)
Auscultation Peristaltic (+)
Aorta abdominal bruit (-), A. Lienalis, A. femoralis (-)
 EXAMINATION RESULTS

Percussion Shifting dullness(-)

Undulation test (-)
Hepar deaf (-)
Liver span dextra 11 cm
Liver span sinistra 6 cm,
Traube’s space (+)
Palpation Mass (-)
Pain (-)
Hepatomegali (-)
Hepar, kidney & lien are normal
Splenomegali (-)
Murphy’s sign (-)

INTERPRETATION Normal
 EXTREMITIES
DATE : 10th December 2017
EXAMINATION SUPERIOR INFERIOR

Oedem -/- -/-

Akral dingin -/- -/-

Refleks patologis -/- -/-

Refleks fisiologis +/+ +/+

Ikterik -/- -/-

LABORATORY TEST
 HEMATOLOGY
DATE : 7th December 2017 / 13.03 WIB/ Sultan Agung Islamic Hospital

PEMERIKSAAN HASIL NILAI NORMAL SATUAN

Hemoglobin 11 (L) 13.2-17.3 g/dl

Hematokrit 34.3 33-45 %

Leukosit 9.18 3.8-1-.6 ribu/uL

Trombosit 471 (H) 150-440 Ribu/uL

Golongan darah B / Positif

INTERPRETATION Anemia, trombositosis

 KIMIA
DATE : PEMERIKSAAN HASIL NILAI NORMAL SATUAN
7th December 2017 /
6.27 WIB / Sultan GDS 146 (H) 75-110 mg/dl
Agung Islamic Urine Acid 4.1 3.5-7.2 mg/dl
Hospital Ureum 25 10 - 50 mg/dl
Creatinin Darah 0,94 0.7-1.3 mg/dl
Albumin 2.79 (L) 3.4-4.8 g/dl
SGOT 40 0-50 U/I
SGPT 50 0-50 U/I
Natrium 136 135-147 mmol/L
Kalium 4.01 3.5-5 mmol/L
Chloride 96.2 95-105 mmol/L
INTERPRETATION Hiperglikemi, Hipoalbumin

DATE : PEMERIKSAAN HASIL NILAI NORMAL SATUAN

12th December 2017
/ 20.18 WIB / Total Protein 7.56 6.0-8.0 g/dl
Sultan Agung Albumin 2.55 (L) 3.4-4.8 g/dl
Islamic Hospital Globulin 5.01 g/dl
INTERPRETATION Hipoalbumin
 HEMOSEROLOGI
DATE : 9th December 2017 / 11.41 WIB / Sultan Agung Islamic Hospital

PEMERIKSAAN HASIL NILAI NORMAL SATUAN

HBsAg Kualitatif Non Reaktif Non Reaktif -

INTERPRETATION Normal
 TRANSUDAT/EKSUDAT
DATE : 9th December 2017 / 16.30 WIB / Sultan Agung Islamic Hospital
PEMERIKSAAN HASIL NILAI NORMAL SATUAN
Rivalta Positif -
Analisa LCS
• Warna Kuning Tidak berwarna -
• Kekeruhan Keruh Jernih -
• Glukosa 0 50-60 mg/dl
• Hitung Jumlah Leukosit 325 /mm3
• Hitung Jenis Leukossit
PMN 93 30-40 %
MN 7 60-70 %
• Protein Total 665 15-45 mg/dl
• Pandy Positif Negatif -
• Nonne Positif Negatif -
• Klorida 103.2 mmol/dl
INTERPRETATION Eksudat
 PEMERIKSAAN BTA
DATE : 11th December 2017 / 08.05 WIB / Sultan Agung Islamic Hospital

PEMERIKSAAN HASIL NILAI NORMAL SATUAN

Bahan Pemeriksaan :
Sputum
P BTA (Sputum) Pagi Negatif Negatif : Tidak
BTA : negatif ditemukan BTA dalam
Leukosit : >25/LP 100 LP
Epitel : 0-1/LP Scanty : Ditemukan 1-9
BTA dalam 100 LP
1+ : 10-99 BTA dalam
100 LP
2+ : 1-10 BTA setiap 1
LP
3+ : >10 BTA setiap 1
LP
INTERPRETATION Normal
DATE : 11th December 2017 / 08.07 WIB / Sultan Agung Islamic Hospital

PEMERIKSAAN HASIL NILAI NORMAL SATUAN

Bahan Pemeriksaan :
Cairan Pungsi perikardi

Pengecatan BTA BTA : Negatif

INTERPRETATION Normal

MIKROBIOLOGI
DATE : 11th December 2017 / 08.05 WIB / Sultan Agung Islamic Hospital

PEMERIKSAAN HASIL NILAI NORMAL SATUAN

Kultur dan Sensitivitas
Pus
Bahan Pemeriksaan : Tidak terdapat
Cairan Pungsi pericardi pertumbuhan kuman

INTERPRETATION Normal
X - RAY
DATE : 7th December 2017 / Sultan Agung Islamic Hospital
Description
Cor : apeks ke laterocaudal, pinggang jantung mendatar
Pulmo : corakan vaskuler tak meningkat
tak tampak gambaran infiltrat
Diafragma setinggi costa 10 poterior
Sinus kostofrenikus kanan kiri suram

KESAN :
◦ KARDIOMEGALI (LV, LA), DD/- PERICARDIAC
EFFUSIONS
◦ PULMO TAK TAMPAK GAMBARAN INFILTRAT
◦ EFUSI PLEURA BILATERAL MINIMAL
DATE : 11th December 2017 / Sultan Agung Islamic Hospital
Description
Dibanding foto sebelumnya tanggal 7 Desember 2017
Cor : CTR : tidak dapat dinilai. Bentuk dan letak normal
Pulmo : corakan vaskuler tak meningkat
tak tampak gambaran infiltrat
Diafragma setinggi costa 10 poterior
Tampak perselubungan pada laterobasal hemithorax kiri, dibanding
sebelumnya bertambah
Sinus kostofrenikus kanan tumpul, kiri suram.

KESAN :
◦ BENTUK DAN LETAK NORMAL
◦ PULMO TAK TAMPAK GAMBARAN INFILTRAT
◦ EFUSI PLEURA KANAN MINIMAL, BERKURANG
DIBANDING SEBELUMNYA
◦ EFUSI PLEURA KIRI BERTAMBAH
ECG
DATE : 7th December 2017 / Sultan Agung Islamic Hospital
Description
Rhytme : reguler
HR : 136 bpm
Axis : Lead I (-) aVF (+)  Deviasi Kanan
Transitional Zone : tidak dapat dinilai
P wave : normal, P pulmonal (-) P mitral (-)
PR Interval : 0,12, normal
QRS Complex : 0,08, normal
ST Segment : ST depresi (-) ST elevasi (-)
T wave : normal

Interpretation : Sinus Takikardi

ECHOCARDIOGRAPHY
1.
DATE :
8th December 2017 / Sultan Agung Islamic Hospital
Deskripsi:
• Dimensi Ruang Jantung : Tidak membesar
• Dinding LV : Tidak menebal
• Wall otion : Global Normokinetik
• Katup jantung : Normal
• Fungsi LV Sistolik baik EF 57%
• Fungsi RV sistolik baik TAPSE 20mm
• Fungsi diastolic gangguan relaksasi
Kesan
• Global normokinetik
• Fungsi LV dan RV sistolik baik
• Disfungsi LV Diastolik
• EFUSI PERIKARD MODERATE SEVERE
2.
Date :
9 December
2017/ Sultan
Agung Islamic
Hospital

KESAN:
Cairan efusi
perikard
berkurang
 ABNORMALITY DATA
Anamnesis
1. Dispneu Advance Examination
2. Cough Laboratory Test
3. Chest pain 6. Hipoalbumin

X- Ray
9. Efusi Pleura

Physical Examination ECG

Pulmo
4. Stem fremitus deacresed ECHO
5. Dullness 11. Efusi Perikard Moderate severe
 PROBLEM LISTS
1 EFUSI PLEURA

1. Dispneu 3 HIPOALBUMIN

2. Cough 6. Hipoalbumin
3. Chest pain
4. Stem fremitus deacresed
5. Dullness
9. RO: Efusi Pleura 4 SVT

2 EFUSI PERIKARD

1. Dispneu
5.

2. Chest pain
11. Efusi Perikard Moderate severe
 Pleural Effusion
• Ass: -
• IP Dx : -
• IP Tx :
• Pungsi Pleura
• IP Mx :
• Monitoring pleural drainage
• IP Ex :
◦ Explain about his diseases, Bed rest, avoid more activity
◦ Consume drugs regularly
 Pericard Effusion
• Ass:
• DD:
• IP Dx : -
• IP Tx :
• IP Mx :
• IP Ex :
 HIPOALBUMIN
IP Dx: -

IP Rx:
Albumin correction  (Albumin target – Alb actual) x BB x 0.8 = (gr)
Alb corr : (3,5 – 2,46) x 42 x 0,8 = 34,944 gram
preparat albumin
20% in 50 cc 10 gr
20% in 100 cc 20 gr
25% in 50 cc  12.5 gr
25% in 100 cc  25 gr

IP Mx:
albumin count

IP Ex:
high intake protein
 SVT
Ass:
◦ Automatic tachycardi
◦ AVNRT (AV node reentrant tachycardy)
◦ AVRT (AV reentrant tachycardy)

IP.D x: Cardiac electrophysiology

IP. Tx:
◦ Pharmacology
◦ Propanolol 40 mg 2x1
◦ Non Pharmacology
◦ Masase karotis
◦ Rangsangan mekanik dengan pemukulan dada

IP. Mx:
◦ Monitoring EKG

IP. Ex:
◦ Explain about disease
PERICARDIAL EFFUSION