CBD
CASE BASE DISCUSSION
MUHAMMAD SUKRON
30.10120.6682 Advisor :
dr. H. M. SAUGI ABDUH, Sp.PD., KKV, FINASIM
Department of Internal Medicine
Medical School of Sultan Agung Islamic University
2016
Name : Mrs. S
Age : 49 years old
Gender : Female
Religion : Moslem
Job : Housewife
Address : Kudu RT 05/05, Genuk Semarang
MR number : 129.22.44
Room : Baitul Izzah 1 410.4
Entry date : August 10th, 2016
Date out : August 14th, 2016
HISTORY TAKING
Main Dyspneu
Problem
Patient came into policlinic department of Islamic
History
of Hospital of Sultan Agung Semarang Complained
Present about her abnormal breathing (dyspneu). Its started 3
Illness days ago when do activity. Patient usually wake up in
the midnight when he felt dyspneu. The patient had
dispnue since more than one month ago. Patients also
complained weak and loss of appetite. Patient need
more pillow when slept to decrease her dispneu.
HISTORY OF ILLNESS
HISTORY OF PREVIOUS ILLNESS
SOSIO-ECONOMIC HISTORY :
Hypertension history (+)
Hospital cost certified by
DM history (-)
JKN NON PBI
Asthma history (-)
Alergy history (-)
Dhiarrea history (+)
FAMILYS HISTORY OF DISEASE
Hypertension history (+)
DM history (-)
Asthma history (-)
Alergy history (-)
SISTEMIC ANAMNESIS
Main Complains : Abnormal breathing (dyspneu)
Onset : 3 days ago
Location : Chest, feel hard to breath.
Chronology : She Complain that 3 days ago he feel hard to
breath when daily activity. The breath feel more
better when she take a rest
Quality and Quantity : Patient feel hard to breath everytime and
disturbing activities.
Modification factor : He felt better when break the activity and sit
back relax.
Comorbid complains : Weak, headache, and cough
PHYSICAL EXAMINATION
General : dyspneu (+),weakness
Skin : itching (-), redness (-),jaundice (-), pale (-), slick (-),
Head : headache (+)
Eyes : blurred vision (-), red eyes (-), icteric sclera (-/-), exoftalmus (+/+)
Jafroy dign (+), rossenbacht (+), mobius sign (-), fon grave sign (+/+),
stelwagh sign (-)
Ears : hearing loss (-), ring (-), discharge (-)
Nose : nosebleed (-), discharge (-), nostril breath (-)
Mouth : cyanosis (-), thrush (-), bleeding gums (-)
Throat : pain swallow(-), hoarseness (-), difficult in swallowing (-)
Neck : enlargement of the gland/thyroid (+/+)
Chest : cough (+), sputum (-), blood (-)
Cardiac : chest pain (-), palpitations (-)
Digestive : abdominal pain (-), nausea (-), vomiting (-)
GENERAL STATUS
BMI (Body Mass Indeks)
weight : 48kg BMI=48: 1,50 = 21,3
High : 150cm
Intepretation :
NormoWeight
General : Dyspneu
Awareness : Fully aware / Compos Mentis
Vital Sign :
Blood Pressure : 170/85 mmHg
Heart rate : 80 x/minute
Breath Frequency : 28 x/minute
Temp : 36,5oC Intepretation :
Hypertension stage II
GENERAL STATUS
Head : Mesocephal, alopesia (-)
Eyes : Anemic Conjuntiva(-/-),Icteric sclera(-/-), exoftalmus (+/+)
Nose : symmetric, secret (-), Nostril Breath (-)
Ears : Normal Shape, discharge (-/-)
Esophagus : Hyperemic (-), pain devour (-)
Mouth : Cyanosis (-), dry lips (-),
Neck: Trakhea deviation (-), Lymph Hypertropy (-), enlargement
thyroid glands (+/+)
Extremity : Oedem of lower extremity / upper extremity (-) / (-)
plakat eritematous with soft skuama (-)
Intepretation : Enlargement thyroid glands,
exoftalmus
LUNG EXAMINATION
INSPEKSI ANTERIOR POSTERIOR
Static RR : 28x/min, Hyper pigment (-), spider nevi RR : 28x/min, Hyper pigment
(-), atrophy Pectoral Muscle (-), Hemithoraks (-),spider nevi (-), Hemithoraks D=S,
D=S, ICS Normal, Diameter AP < LL ICS Normal, Diameter AP < LL
Dynamic Up and down of hemitoraks D=S, Up and down of hemitoraks D=S,
abdominothorakal breathing, (-), muscle abdominothorakal breathing (-), muscle
retraction of breathing (-), retraction of breathing(-),
retraction ICS (-) retraction ICS (-)
Palpation Palpable pain(-), tumor (-), Arcus costae angle Palpable pain (-), tumor (-), Stem
< 900, enlargement of ICS (-), Stem fremitus fremitus D=S
D=S
Percution Sonor Sonor
Auskultation Vesicular (-), Whezzing (-), Ronchi (-) Vesicular (-), Whezzing (-), Ronchi (-)
Intepretation : Normal
CARDIAC EXAMINATION
Inspection : Ictus cordis isnt seen.
Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-),
sternal lift (-).
Percussion : dull sound
Upper borderline of heart : ICS II left sternal line
Waist of heart : ICS III left parastern line
Lower right borderline of heart : ICS V right sternal line
Lower left borderline of heart : ICS VI, 2 cm lateral from left
mid clavcle line
...CONT
Auscultation
Aortal valve : S1 & S2 standard, additional sound (-)
Pulmonary valve : S1 & S2 standard, additional sound (-)
Tricuspid valve : S1 & S2 standard, additional sound (-)
Mitral valve : S1 & S2 standard, additional sound (-)
Intepretation : Cardiomegaly
ABDOMEN EXAMINATION
Inspection : symetric, sycatric(-), striae(-),enlargement of vena (-),
caputmedusa (-), plakat eritematous with soft skuama (-)
Auscultation : peristaltic (-)
Palpation :
Superfisial : tight (-), mass (-)
Deep : abdominal pain (+), liver, kidney, and spleen werent
palpable, Murphys sign (-)
Percussion : tympani, side of deaf (-), shifting dullness (-)
Liver : deaf(+), right liver span 11 cm, left liver span 6 cm
Spleen :Throbe space percussion (+) tympani
Intepretation : Normal
EXTREMITIES EXAMINATION
Ekstremitas Superior Inferior
Oedema -/- -/-
Cold -/- -/-
Jaundice -/- -/-
LAB. EXAMINATION
10/8/2016 Hematology 12/8/2016 Hormon
Hb 11,8 g/dl TSHs <0,05
Ht 35,1% Free T4 >100
Leukosit 5,47 ribu/uL 10/8/2016 Kimia
Trombosit 170 ribu/Ul GDS 138
27/10/2015 Kimia
Natrium 141.3 mmol/L
Intepretation : Kalium 4,30 mmol/L
Hyperthyroid Chloride 100 mmol/L
X-RAY THORAX
Intepretation :
1. Cor : CTR > 50%
2. Pulmo : corakan bronkovascular
normal,tak tampak bercak pada
kedua paru
Diafragma dan sinus kostofrenikus baik
KESAN:
Cor : CARDIOMEGALI
Pulmo : Tidak tampak kelainan
ECG (11/08/2016)
Ritme : Atrial
REGULARITAS : Irregular, Irreguler
FREKUENSI : 90x/minutes (normal respons)
GELOMBANG P : abnormal, P wave disappear/small
PR INTERVAL : unidentified
QRS COMPLEX : 2 x 0,04 = 0.08 (Normal)
ST SEGMEN : 4 x 0,04 = 0,16 (Normal), isoelektris
GELOMBANG T : Normal
ZONA TRANSISI : V3
AXIS : Lead I (+) dan aVF (+) : NAD
Intepretation : Atrial Fibrilation
ECHO
Dimensi ruang jantung : Membesar di LA
Dinding LV : Tidak menebal
Wall motion : Global Normokinetik
Katup jantung : Normal
Fungsi RV sistolik baik : TAPSE 1,7 mm
Fungsi LV Diastolik gangguan relaksasi
Fungsi LV sistolik Baik EF 64%
Kesan:
Global Normocinetic
Normal of sistolic RV & LV function,
Mild disfunction of diastolic
Dilatation of LA
Abnormal Data
History Taking
1. Dyspneu, 2.
dispneu
deffort, 3. Ro Thoraks :
orthopneu 10.Cardiomegaly
4.weak
5.Headache ECG : Lab
6. dhiarrea 11. Atrial Fibrilation Hematology
14.Hyperthyroid
Physical
ECHO
Examination
12. Mild disfunctin of
7.Enlargement of
diastolic
Thyroid glands
13. Dilatation of LA
8.Exoftalmus
9.High blood
preasure : 170/85
PROBLEM LIST
1 2 3
CHF NYHA 2 HYPERTENSION HYPERTHYROID
(1, 2,3,4,5,9,12) STAGE II ( 6,7,10,15)
( 7)
4
ATRIAL
FIBRILATION
( 6,7,10)
1. CHF NYHA 2
Ass: Etiologi : Thyroid Heart Disease
Anatomi :-
Fungsional : NYHA II
IP Dx : BNP and Pro-BNP
IP Tx :
Non Pharmacology Pharmacology
Low Fat Intake Infus RL 30 tpm
Low Salt intake Laktulosa syr 1 x 1
Reduce activity Asam Folat 1x1
High fiber Diet Propanolol 10mg 2x1
Ip. Mx : Vital sign, ECG, ECHO
Ip. EX :
Bed Rest/Restriction of physical activity
Sodium & Fluid `restriction
Reducing Emotional stress
Sit position or a half sleep position
2. 2nd Grade Hypertension
Ass :
- Risk factor cardiovascular (HT) : DM, dislipidemia, obesitas
- Hyperthyroid
Ip Dx : LDL, HDL, trigliserid, total cholesterol, waist circumference, uric acid
Ip Tx :
Non Pharmacology :
Low salt intake
Do exercise
Pharmacology :
Captopril 2 x 12.5 mg
Amlodipin 1 x 5 mg
Ip. Mx : Vital Sign
Ip.Ex :
Diet low salt
Consumption vegetable, fruit
Routine consumption drugs
American Society of Hypertension and the International Society of Hypertension 2013
3. GRAVES DISEASE
Ass : -
IP Dx : -
IP Tx : Non pharmacology
Pharmacology - High calori (food, suplemen)
-Tirosol 5 mg 2x1 - High protein
-Propanolol 10 mg 2x1 - Do exercise
Ip. Mx : Lab (TSHs, T4), sign and symtom
Ip. EX :
- routine consume medicine
Propanolol (B-Blocker)
4. ATRIAL FIBRILASI
Ass: thrombo-embolism
IP Dx : -
IP Tx :
Pharmacology : Warfarin 5 mg/ day
Non pharmacology : Diet low fat
Ip. Mx : EKG 12 lead, PT, INR
Ip. EX : explain about his disease to his family
CHA2DS2-VASc Score
CHF YES
HIPERTENSION YES
AGE >65 TH NO
DM NO
STROKE NO
VASCULAR DISEASE NO
MALE NO
CHA2DS2-VASc SCORE 2
RISK CATEGORY MODERATE RISK
ANTITHROMBOTIC RECOMENDATION ORAL ANTICOAGULATION
HAS-BLED Score
HIPERTENSION (SBP >160 MMHG) YES
ABNORMAL RENAL FUNCTION NO
ABNORMAL LIVER FUNCTION NO
AGE > 65 NO
STROKE NO
PRIOR MAJOR BLEEDING NO
LABILE INR NO
TAKING DRUGS PREDISPOSING BLEEDING YES
ALCOHOL USE NO
HAS-BLED SCORE 2
RISK CATEGORY MODERATE
ESTIMATED MAJOR BLEEDING 4,9-19,6%
TERIMAKASIH
