Laporan Kasus

Perempuan 42 tahun dengan HT Emergensi, DM Tipe 2, Vertigo

dan Anemia

dr. IBNU I. RIZAL

INTERNSIP RSI PKU MUHAMMADIYAH TEGAL
TEGAL, 06 NOVEMBER 2019
IDENTITAS PASIEN

Nama : Ny. A
Usia : 42 tahun
Jenis Kelamin : Perempuan
No. CM : 15.36.07
Alamat : Jenggawur 05/02 pangkah
Bangsal : Multazam atas B
Autoanamnesis dengan pasien (20/10/2019) pukul 15.30 WIB
Ny. A / 42 Tahun/ Multazam atas A

Riwayat Penyakit Sekarang

Keluhan utama: pusing

Pasien mengeluh pusing berputar sejak 2 jam SMRS. Keluhan di rasakan

mendadak saat pasien bangun tidur, Keluhan tersebut di sertai mual (+)
muntah 2 x , 5 jam sebelumnya pasien mengeluhkan pusing di seluruh
bagian kepala, kaku di otot leher, pasien juga mengeluhkan lemas, Keluhan
lain tidak ada.
Riwayat penyakit terdahulu
Riwayat hipertensi (+) tak terkontrol dan Diabetes (+) tak terkontrol.

Riwayat pengobatan
pasien beli obat pusing di warung  Belum membaik.

Riwayat penyakit keluarga

Tidak didapatkan riwayat sakit yang serupa pada keluarga.

Riwayat sosial
Pasien bekerja sebagai ibu rumah tangga
Pemeriksaan Fisik
Keadaan umum : cukup GCS 456 VAS: 4/10
TD : 200/100 mmHg HR 115 x/mnt regular RR : 24 x/mnt Tax : 36,5 0C
SpO2 : 97%
Kepala Conjunctiva pucat (+/+), sklera icteric (-),
Thorax : Cor S1, S2 single, murmur (-), gallop (-)

Pulmo Statis D=S, stem fremitus normal Percution sonor sonor SN V V Rh - - wheezing - -
Dinamis D=S normal sonor sonor V V -- --
normal sonor sonor V V -- --
Abdomen flat, bowel sound normal, liver span 9 cm and traube’s space: tympani, epigastrium tenderness (-)
Nyeri tekan (-),
Extremities Akral hangat
Pitting oedema -/-
Laboratorium tgl 20-10-2019
Lab Nilai Nilai Rujukan

Hemoglobin 10,3 g/Dl 13,4-17,7

Eritrosit 4,29 /Ul 4,0 - 5,5.106

Leukosit 18,100 /Ul 4,3-10,3.103

Hematokrit 40,1% 40-47

Trombosit 306.000 /Ul 142-424.103

MCV 70,1,2 Fl 80-93

MCH 24,0 pg 27-31

MCHC 34,3 g/Dl 32-36

Glukosa sewaktu 228 mg/dl 70-120

HitungJenis:
Granulosit % 78,9 % 35-80
MID% 3,5 % 2,0-15.0
Limfosit 17,6 % 15.0-50.0
Pemeriksaan Penunjang
EKG 20/10/ 2019

Irama Sinus 115 x/ menit reguler, frontal axis normal, horizontal axis normal, komplek QRS 0.06 detik, interval PR 0,16
detik, gel P tinggi 0,2 mV lebar 0,8 detik, segmen ST isoelektris. Gel T normal, Gel S V2 dan gel R V5 37 mV,
Kesimpulan: Takikardi, Hipertrofi ventrikel kiri
 DAFTAR MASALAH & DIAGNOSIS

DIAGNOSIS
1. Hipertensi Emergensi
2. DM Type 2
No Masalah Aktif Tanggal 3. Vertigo
1 Pusing berputar 20/10/2019 4. Anemia
2 Mual, Muntah 20/10/2019
3 TD 200/100 20/10/2019
4 HB 10,3 20/10/2019
5 GDS 228 20/10/2019
6 Leukosit 18.100 20/10/2019
TERAPI

pTx : pMx : keadaan umum, tanda vital

IV pEx: edukasi tentang penyakit yang dialami serta

 Infus Herbeser 50 mg + RL 12 tpm s/d TDS edukasi tentang kapan harus melapor kepada petugas
150 mmHg kesehatan.
 Injeksi ceftriaxone 2x1gr
 Injeksi Ondansetron 2x4mg

P.o
 Amlodpin 0-0-10 mg
 Candesartan 8mg-0-0
 Betahistin 3 x 6mg
 Glimepirid 2mg-0-0

Program
 Diet HT, DM
 Cek gds per hari
 FOLLOW UP
20/10/2019:
S : pusing berputar” (+) mual
(+), lemas (+),
O : TD 15.00 190/100 mmHg
16.00 190/100 mmHg
18.45 190/100 mmHg
20.00 190/100 mmHg
P: Terapi lanjut
21/10/2019: 22/10/2019: 23/10/2019:
S : pusing berkurang (+) S : (-) S : (-)
O : TD 01.00 160/90 mmHg O : TD 06.00 170/90 mmHg O : TD 06.00 170/90 mmHg
06.00 160/90 mmHg 12.00 160/90 mmHg 12.00 160/90 mmHg
12.00 160/90 mmHg 20.00 170/90 mmHg 18.00 160/80 mmHg
20.00 170/90 mmHg
P: - Terapi lanjut P: Boleh Pulang
- Po Clonidin 1x1 tab
P: - Drip Herbeser Tap Off
(07.00 WIB)
(01.00 WIB)
- Terapi lanjut
Discussion
what are the guidelines
for managing
hypertension ?
Classification of
Blood Pressure
Classification of
Blood Pressure
Classification of
Blood Pressure
Classification of
Blood Pressure
Definition

Hypertensive crises are acute, severe elevations in

blood pressure that may or may not be associated
with target-organ dysfunction.

(Scott T. Benken, Pharm.D., BCPS-AQ Cardiology,2018).

Risk factors and causes

 female sex
 higher grades of obesity
 presence of coronary heart disease,
 presence of mental illness
 patient nonadherence to antihypertensive
medications (Most Common)
small longitudinal analysis from Switzerland

(Scott T. Benken, Pharm.D., BCPS-AQ Cardiology,2018)

Classification of
Hypertensive Crises

Emergency hypertension

Hypertensive emergencies are characterized by severe elevations in BP ( >180/120 mm Hg)

complicated by evidence of impending or progressive target organ dysfunction

urgency hypertension

Hypertensive urgencies are those situations associated with severe elevations in BP without
impending or progressive target organ dysfunction.

( Seventh report of the joint national committee, 2003)

Classification of
Hypertensive Crises

Emergency hypertension

Hypertension emergencies are situations in which severe hypertension (grade 3) is associated

with acute HMOD,

urgency hypertension

hypertension urgencies are severe hypertension (grade 3) in patients there is no clinical

evidence of acute HMOD.

( ESC/ESH Guidelines for the management of arterial hypertension. 2018 )

Classification of
Hypertensive Crises

Emergency hypertension

severe elevations in blood pressure (systolic blood pressure ≥ 180 mm Hg or diastolic blood
pressure ≥ 120 mm Hg) with Target organ damage new/ progressive/worsening

urgency hypertension

severe elevations in blood pressure (systolic blood pressure ≥ 180 mm Hg or diastolic blood
pressure ≥ 120 mm Hg) without evidence of end-organ dysfunction

(AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adult,2017 )
Diagnostic workup for patients with a suspected hypertension
emergency

Common tests for all potential causes Specific tests by indication

- funduscopic examination - Chest X-ray (fluid overload)

- 12-lead ECG - Echocardiography (aortic dissection, heart failure, or
- serum glucose ischaemia)
- Creatinine - head or chest CT
- Electrolytes - troponin, CK-MB (in suspected cardiac involvement,
- CBC e.g. acute chest pain or acute heart failure)
- liver function tests
- urinalysis (in search of proteinuria and hematuria)
- Pregnancy test in women of child-bearing age

( ESC/ESH Guidelines for the management of arterial hypertension. 2018 )

 Most common Target
Organ Damage and Clinical
Manifestations

(Scott T. Benken, Pharm.D., BCPS-AQ Cardiology,2018).

Pathophysiology of
Hypertension Emergency

(Devicaesaria, 2014)
Management of Hypertension
Emergency

(AHA Guideline for the Prevention, Detection, Evaluation, and Management of

High Blood Pressure in Adult,2017 )
Drug of Choice

(AHA Guideline for the Prevention, Detection, Evaluation, and Management of

High Blood Pressure in Adult,2017 )
Drug of Choice

(AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood
Pressure in Adult,2017 )
Drug of Choice

( ESC/ESH Guidelines for the management of arterial hypertension. 2018 )

Drug of Choice

( ESC/ESH Guidelines for the management of arterial hypertension. 2018 )

Drug of Choice

( seventh report of the joint national committee, 2003)

Drug of Choice

( Wijaya indra and Siregar parlindungan, 2013)

How to calculate mean arterial pressure ?

MAP = SBP + 2 (DBP)

3
MAP = 83 +2 (50)
3
MAP = 83 +100
3
MAP = 183
3
MAP = 61 mm HG
MATUR
NUWUN
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