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CASE BASE DISCUSSION

Rheza Rizaldy
30101407301

ADVISOR
dr. H.M Saugi Abduh, Sp.PD, KKV, FINASIM
 Name : Mr. MRDG

 Date of birth : 10th February 1969

 Age : 49 yo

 Gender : Male

 Religion : Islam

 Occupation : Driver

 Address : Tambak Mulyo,


Semarang

 MR Number : 013130185

 Room : Baitul Ma’ruf

 Entry Date : 25th November


2018
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A male patient, 49 yo, came to the ER of Sultan
Agung Islamic Hospital complaining about the pain on his
left side of chest since ± 3 days before he came to the
Main problem hospital. He also complained about his difficulties in
breathing when he does regular activity such as walking
around and also swelling on both of his legs .These
symptoms are getting worse when he is working and will be
CHEST PAIN much better when he is on a rest He has history of
hypertension, and smoking.

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Main problem

Main problem

Chest pain
CHEST PAIN
Onset:

± 3 day before come to the hospital Modified factor:


Location: Left side of chest
These symptoms are getting worse when he
Quantity and quality:
is working and will be much better when he is
Depressed Chest pain and feels constantly

Cronology:
on a rest.

The patient feels pain while working three days before he Other sytmpom :
came to the hospital
Dsypneu and swelling on both legs

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Riwayat Penyakit Riwayat Penyakit Riwayat Sosial-
Dahulu Keluarga Ekonomi

• Hipertension (+)
• DM (-)
• Hipertension • Alcohol (-)
• Allergy (-)
(+) • Smoking (+)
• Asthma (-)
• DM (-)

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Awareness : Compos Mentis ×MAP (Mean Atrial Pressure)
×= 2D+1S/3
Vital Sign : ×= ((2 x 112) + 164) /3
×= (224 + 164)/3
Blood Pressure : 164/112 mmHg ×= 129,3 mmHg
Heart rate : 101 x/minute

Breath Frequency : 26 x/minute


Interpretasi: Grade II
Temp : 36,5 oC
Hypertension, Tachycardia,
Tachypneu
×BMI (Body Mass Indeks)

×Weight : 90 kg BMI = 31,51 Kg


×Height : 169 cm
×Abdominal Circumference = 102 cm
Interpretasi: Grade I Obessity
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General : Lemas
Kulit : gatal (-), jaundice (-), pucat (-)
Kepala : pusing (-)
Mata : penglihatan kabur (-), mata cekung (-), sklera ikterik (-/-),
konjungtiva anemis (-)
Telinga : pendengaran menurun (-), discharge (-)
Hidung : perdarahan (-), discharge (-)
Mulut : sianosis (-), bibir kering (-), mukosa pucat (-), thrush (-), bleeding
gums (-)
Tenggorokan : nyeri telan (-), hoarseness (-), sulit menelan (-)
Leher : pembesaran KGB (-)
Thorax : cough (-), sputum (-), blood (-), sesak (+)
Cardiac : nyeri dada (+), palpitations (-)
GIT : nyeri perut (-), mual (-), muntah (-)
Musculoskeletal : weak (-), rigid (-), back pain (-)
Ekstremitas : lower extremities oedema (+) 7
INTERPRETASI :
Thorax-Pulmo Examination Tachypneu, Pulmonary
Oedema
INSPEKSI ANTERIOR POSTERIOR

Static RR : 26x/min, Hyper pigment (-), spider nevi RR : 26x/min, Hyper pigment (-), spider nevi (-),
(-), atrophy Pectoral Muscle (-), Hemithoraks D=S, ICS 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 (-), Arcus costae angle < 900, Palpable pain (-), tumor (-), Arcus costae angle < 900,
enlargement of ICS (-), Chest Expantion (normal), enlargement of ICS (-), Chest Expantion (normal),
Stem fremitus D=S Stem fremitus D=S

Percussion redup (+/+) redup (+/+)

Auskultatio Vesicular (-), Whezzing (-), Basal Rales(+/+) Vesicular (-), Whezzing (-), Basal Rales(+/+)
n
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Inspection : Ictus cordis isn’t seen.
Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-), sternal lift (-).
Percussion : dull sound
- Upper borderline of heart: ICS II left sternal line
INTERPRETASI :
- Waist of heart : ICS III left parasternal line
• Cardiomegaly (latero
- Lower right borderline of heart : ICS V right sternal line
caudal)
- Lower left borderline of heart : ICS VI left anterior axillary line
• Aorta Regurgitation
Auscultation
• Tricuspid Regurgitation
Aortal valve : S1 standard & S2 murmur, additional sound (-)
• Mitral Regurgitation
Pulmonary valve: S1 & S2 standard, additional sound (-)
Tricuspid valve : S1 murmur & S2 standard, additional sound (-)
Mitral valve : S1 & S2 murmur, additional sound (-)

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sikatrik(-), striae(-), caput medusa (-),
INSPEKSI
hiperpigmentasi (-), spider nevi (-)

AUSKULTAS Bising peristaltik (+)  20 kali/menit, bising


I pembuluh darah (-)
Perkusi 4 regio : timpani
Abdominal
Hepar : pekak (+), liver span dextra 10 cm, sinistra
7 cm
PERKUSI
Lien : troube space : Timpani
Ginjal : nyeri ketok ginjal (-)
Interpretasi : Normal
Test undulasi (-)

Superfisial  Nyeri tekan epigastrium (-), Massa (-


), defence muscular (-)
PALPASI Dalam  Nyeri (-), Nyeri alih (-)
Murphy’s sign (-)
 Turgor kulit : normal 10
EKSTREMITY Superior Inferior

Oedem -/- +/+

Cold acral -/- -/-


Ekstremitas

Capillary refill <2 second <2 second

Ulcus -/- -/-


INTERPRETASI : lower
extremities oedema +
Reflex Fisiologis +/+ +/+

Reflex Patologis -/- -/-

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Pemeriksaan Hasil Nilai Normal
Laboratory
HEMATOLOGI
Examination
Hemoglobin 15,6 g/dL 13,2 – 17,3 g/dl (25 November
2018)
Hematokrit 44,4 % 33 – 45 %

Leukosit 10,39 ribu/uL 3,8 – 10,6 ribu/uL

Trombosit 197 ribu/uL 150 – 440 ribu/uL

Golongan Darah/Rh AB / positif

KIMIA Hasil Nilai Normal Interpretation


Normal
Ureum 32 mg/dL 10 - 50 mg/dL

Creatinin darah 1,27 mg/dL 0,6 – 1,3 mg/dL


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Pemeriksaan Hasil Nilai Normal

KIMIA
Gula Darah Sewaktu 84 mg/dL (H) 75 – 110 mg/dl

Cholesterol 139 mg/dl <200 mg/dl

Interpretation
Trigliserid 59 mg/dl <160 mg/dl
Normal
HDL 31 mg/dl 28-63 mg/dl

LDL 103 mg/dl (L) 60-130 mg/dl

Uric Acid 6,0 g/dl 3,5-7,2 mg/dl

SGOT 31 U/I 0-50 U/I

SGPT 35 U/I 0-50 U/I 13


Pemeriksaan Hasil Nilai Normal

Marker jantung <19 ng/L, tidak ada


High sensitive 938,4 ng/L nyeri dada  rule-
troponin I ( TNHS ) (H) out
>100 ng/L rule in
19-100 ng/L (cek
Interpretation
Elevated Troponin
HS Troponin 3 jam Level
Kemudian, jika T3-
T0 >= 10  rule in

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DATE : 24th Oct 2018 /
Sultan Agung Islamic Hospital
Description

Cor : Apeks ke latero caudal,


Pulmo : increased bronchovascular
pattern with vascular blurring.

Diaphragm and right


costophrenicus are fine, left
costophrenicus sinus is
superpositioned with the heart

Interpretation :
Cardiomegaly (LV)
Pulmonary Oedema
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EKG

Interpretation: Lateral
Ischemia, LAD
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ECG INTERPRETATION

 Rhytm : Sinus
 Regularity : Reguler
 Frequency : 100 x/menit
 P wave : 0,08 s (normal)
 PR interval : 0,12 s (normal)
 Axis : Left Axis Deviation
 Transition zone : Tidak ada
 QRS complex : 0,12 s (normal)
 Q wave : Normal
 ST segment : ST depression on V5 and V6
 T wave : Normal

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ECHO
Dimensi ruang jantung : LA +LV enlargement
Dinding LV : IVS and PW thickening
Wall motion : Global hypokinetic
Katup jantung : Mild TR Moderate MR Mild AR
Fungsi LV sistolik LVEF 34%
Fungsi RV sistolik TAPSE 11 mm
Fungsi LV diastolik baik E/A >1

Kesan:
Global hypokinetic
Fungsi LV+RV sistolik menurun
Dilatasi LA+LV
Contentric LVH
Mild TR Moderate MR Mild AR

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Coronary Angiography

Interpretation: 30% stenosis


of LAD
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ABNORMALITAS DATA
PEMERIKSAAN PENUNJANG
Physical Examination

ANAMNESIS 17. Elevated Troponin I level


7. Grade II Hypertension (938,4 ng/L)
(164/112 mmHg) 18. Cardiomegaly (LVH)
8. Tachycardia (101 x/m) 19. Pulmonary Oedema
1. Chest pain
9. Tachypneu (26 x/m) 20. Lateral Ischemia
2. Dsypneu
10. Grade I Obessity 21. Mild TR
3. Swelling on both of
11. Oedem inferior extremity 22. Moderate MR
legs
12. Basal Rales (+) 23. Mild AR
4. HT history (+)
13. Cardiomegaly 24. Global hypokinetic
5. History of
14. Aorta regurgitation 25. Decreased LV+RV function
hypertension in family
15. Tricuspid regurgitation 26. LA+LV dilatation
(+)
16. Mitral regurgitation 27. Contentric LVH
6. History of smoking
since junior highschool 28. 30% stenosis of LAD

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01 02
CHF NSTEMI

05
Obessity

03 04
Hypertension VHD

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NSTEMI
 Assesment
Mortality Risk  IP Mx
IP Dx a. Vital sign
Grace Risk Score
b. ECG
INR
HAS-BLED score  IP Ex
a. Education about etiology and risk
APTT-PTT factor of NSTEMI
b. Explain about sign and symptoms of
 IP Tx NSTEMI
Non pharmacology c. Rutine control and always taking a
a. O2 (4lpm) in the first 6 hours medication
d. Do not carry out excessive activities
b. Infus RL (20 tpm) (small runs approximately 15-10
c. Bed Rest minutes)
d. Low Chorestrol Intake

Pharmacology
a. Isdn sub lingual 5 mg
b. Aspirin  Loading dose 160 mg 1x1, dosis maintenance 80
mg 1x1
c. Clopidogrel  loading dose 300 mg 1x1, maintenance dose
75 mg 1x1
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CHF NYHA III
 Assesment  IP Mx
Etiology = IHD, VHD, HHD a. Vital Sign

 IP Dx  IP Ex
Biomarker examination a. Education about etiology and risk
a. B-type Natriuretic Peptide (BNP) factor of NSTEMI
b. Explain about sign and symptoms of
b. Pro-BNP NSTEMI
c. Bed Rest/Restriction of physical
 IP Tx activity
Non pharmacology d. Reduce Emotional stress
e. Routine consumption drugs
a. Reduce activity f. Fluid restriction (1,5 L-2L/day)
b. Low fluid and salt intake
c. High fiber diet (e.g vegetable, fruits)
Pharmacology
a. Captopril 25 mg 2x1  hypertension
b. Bisoprolol 2,5 mg 1x1
c. Furosemide 20 mg 2x1  sampai
edem hilang
d. Spironolactone 25 mg 1x1 (for
maintenance)
VHD
 Assesment  IP Mx
× Etiology : LV dilatation a. Vital sign
× Anatomy : TR, MR, AR b. INR (target 2-3 )
× Complication : Thromboembolism c. HAS-BLED score
disease  IP Ex
 IP Dx a. Routine drugs consumption
CHAD2S vascular score b. Reduce excessive activity
 IP Tx c. Educate about side effect of
Non pharmacology therapy
Consult to Sp. BTKV
Pharmacology
Warfarin 2 mg 1 x 1  out of hospital.
(eso = bleeding)
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Grade II Hypertension
 Assesment  IP Tx
Hipertensi benigna Non pharmacology
Hipertensi maligna Sodium restriction
Lifestyle Modification
Complication to organ target
a. Macroangiopathy: Stroke, ACS, Pharmacology
PAD Amlodipine 5 mg 1 x 1
b. Microangiopathy : Hypertensive
retinopathy, Hypertensive  IP Mx
Nephropathy a. Vital sign
 IP Dx b. GDS
a. CT Scan Brain c. Lipid Profile
b. Funduscopy d. Uric Acid
c. Ureum & Creatinin e. Waist circumference
d. ECG  IP Ex
e. Chest X-Ray a. Routine drugs consumption
f. ABPI b. Routine check of blood pressure
g. GDS c. Salt intake restriction (< half of
h. Lipid Profile teaspoon/day)
i. Uric Acid d. Routine exercise (at least 3 times a week)
Grade I Obessity
 Assesment  IP Mx
Cardiovascular risk a. Body Weight
 IP Dx b. GDS
- c. Lipid Profile
 IP Tx d. Uric Acid level
Non pharmacology  IP Ex
Medical Nutrition Therapy × Routine exercise
Lifestyle Modification × Avoid excessive saturated fatty acid
intake