CBD

Advisor:
dr. H. M. SAUGI ABDUH, Sp.PD., KKV,
FINASIM

Presented by :
Septiani Ratna Hapsari
30101407323

Department of Internal Medicine

Medical School of Sultan Agung Islamic University
2019
 PATIENT’S IDENTITY

 Name : Mr. AH
 Age : 78 years old
 Sex : Male
 Religion : Moslem
 Job :-
 Address : Guntur Demak
 Medical Record No : 01.13.23.48
 Room : Baitul Izzah 1
 Entry Date : 21 July 2019
ANAMNESIS
21 July 2019 Baitulizzah 1 NON PBI.
 HISTORY TAKING

Main Problem
“Ortopneu”
 HISTORY TAKING

History of Present Illness

Patient came to emergency room of Sultan Agung Islamic
Hospital. He complained one day ago patient dyspneu which is
getting worse. It felt like there is something suppressed him
chest. It came up when he has activity and better when take a
rest. Patient also complained cough.
 HISTORY OF ILLNESS

Family’s history of Sosio – Economic

History of previous illness
disease History

• Same symptom/illness (+) • Hypertension history (-) • Economic Impression :

• Hypertension history (-) • DM history (-) enough
• DM history (-) • Asthma and alergy history • Hospital cost certified by
• Asthma history (-) (-) own cost
• Alergy history (-)
• Cardiac Disease (-)
• Drug allergy (-)
• Smoking history (+) > 10
years
 SISTEMIC ANAMNESIS
 Chief Complains : Abnormal breathing (Ortopneu)
 Onset : 1 day ago
 Location : Chest
 Chronology : He complain that 1 day ago she feel hard to breath
when daily activity.
 Quality and Quantity : Patient feel hard to breath everytime and disturbing
activities.
 Modification factor : He said that sitting and sleeping with using 2 pillows
can make him in better condition.
 Comorbid complains : Cough.
 GENERAL STATUS

General Status Vital Sign BMI

Ortopneu 85/55 mmHg 48 kg

Composmentis 69 x/minute
158 cm

26 x/minutes 48
_____
= 19 kg/m2
(1,58)2
36,3 0C
Interpretation
98 %
• Ortopneu
• Hipotensi
 PHYSICAL
EXAMINATION
 GENERAL PHYSICAL EXAMINATION

Anemic conjuntiva (-/-) - • Mesocephal (+)

Icteric sclera (-/-) - • Alopesia (-)
• Rambut jagung (-)

Symmetric -
Secret (-) - • Normal shape
Nostril Breath (-) - • Discharge (-/-)

Cyanosis (-) - • Tracheal deviation (-)

dry lips (-) - • Lymph hypertrophy (-)
snoring (-) - • JVP : 5 + 3 cmH2O
Interpretation

• JVP Increasse
 THORAX-LUNG EXAM
PHYS. EX ANTERIOR POSTERIOR

• RR : 26x/min - Pectoral muscle atrophy (-) • RR : 26x/min - Pectoral muscle atrophy (-)
• Hyperpigment (-) - Hemithoraks D=S, ICS Normal, • Hyperpigment (-) - Hemithoraks D=S, ICS Normal,
STATIC • Spider nevus (-) - Diameter AP < LL • Spider nevus (-) - Diameter AP < LL

-Chest expansion D=S - Accessory muscle use (-) -Chest expansion D=S - Accessory muscle use (-)
-Abdominothorakal breathing (+) - IC retraction (-) -Abdominothorakal breathing (+) - IC retraction (-)
DYNAMIC

- Palpable pain (-) - Widening of ICS (-) - Palpable pain(-) - Widening of ICS (-)
-Tumor (-) - Tactile fremitus D=S -Tumor (-) - Tactile fremitus D=S

- Deaf - Deaf

- Vesicular (+) - Ronchi (+) - Vesicular (+) - Ronchi (+)

- Whezzing (-) - Sterm Fremitus - Whezzing (-) Interpretation
- Sterm Fremitus
• Lung Edema
 22 - 18
THORAX-CARDIAC EXAM 2

• Ictus cordis (-)

• Ictus cordis is palpable (+)

• Thrill (-)
• Epigastric pulse (-)
• Parasternal pulse (-)
• Sternal lift (-)

• Upper borderline of heart : ICS II left sternal line

• Waist of heart : ICS III left parasternal line
• Lower right borderline of heart : ICS V right sternalis line
• Lower left borderline of heart : ICS VI, Linea Axillaris Anterior

Interpretation

Cardiomegali
 THORAX-CARDIAC EXAM
Aorta valve : S1 & S2 standart,
additional sound (-) Pulmonary valve : S1
& S2 standart,
additional sound (-)

Mitral valve : S1 &

S2 standart,
tricuspid valve : S1 & S2 additional sound (-)
standart, additional sound
(-) Interpretation
Cardiomegali
 ABDOMEN EXAM
TYPE OF EXAMINATION RESULTS
Skin
• Scars (-)
• Striae (-)
• Dilated veins (-)
Spider angioma (-)
• Rashes and lesions (-)
• Caput Medusa (-)
Umbulicus Bulging (-)
Contour Round, Enlarge, Symmetric,
Peristaltic (-) Unseen
Bowel sounds 10x/m, click and gurgle (-), metallic sound (-), bruit (-)

Lapang abdomen Timpanic

Hepar Hepar dextra 12cm and sinistra 7cm
Traube's space Timpanic (+)
Asites Shifting dullness (-)
 ABDOMEN EXAM
TYPE OF EXAMINATION RESULTS
Light Muscular defence (-), pain (-), fluid wave test (-), distended stomach (-)

Deep Pain on right and left upper quadran (-) , visceral organ not palpable

Hepar Normal

Suffner (Lien) Normal

Ren Pain on right and left ren (-)

Mc. Burny and Contra -

Murph sign -

Interpretation
NORMAL
 EXTREMITIES

EXAMINATION SUPERIOR INFERIOR

OEDEM -/- +/+

Akran dingin -/- -/-

Refleks Patologi -/- -/-

Refleks Fisiologi +/+ +/+

Ikterik -/- -/-

INTERPRETATION NORMAL NORMAL

Interpretation

Pitting Edema
 ADDITIONAL
EXAMINATION
 LABORATORY TEST
HEMATOLOGI : DARAH HASIL 19- NILAI SATUAN KETERANGAN
RUTIN 1 5-19 RUJUKAN

HEMOGLOBIN 11.6 13.2 – 17.3 g/dl L

HEMATOKRIT 34.5 33 - 45 % N
Interpretation
LEUKOSIT 6.75 3.8 – 10.6 Ribu/uL N

TROMBOSIT 164 150 - 440 Ribu/uL N

• Anemia
GOLONGAN DARAH/Rh B/Positif
 LABORATORY TEST
KIMIA DARAH HASIL 19-2- NILAI SATUAN KETERANGA
18 RUJUKAN N

GDS 109 75 - 110 mg/dl N

Kolestrol 226 <200 mg/dl H

Trigliserid 186 <160 mg/dl H

Interpretation
HDL 33 28-63 mmol/L N

LDL 205 60-130 mmol/L H

• Dislipidemia
Asam Urat 12.7 3.5-7.2 mmol/L H
• Hiperuricemia
• Hipertrygliserid
Troponin I 38.4
 ECG

• Rhytm : Sinus • PR interval : tidak bisa dinilai

• Regularity : Reguler • QRS complex : tidak bisa dinilai Interpretation
• Frequency : 1500/25 = 60x/minute • Q patologi :- • Iskemik
• Axis : I (+), aVF (-)  LAD • LVH/RVH :- anteroinferior
• Transision zone : V4 • ST segment :-
• P-wave : 0.04 s • T-wave : inverted lead II, III, aVF,
V3,V4,V5,V6
 ECG

• Rhytm : Sinus • PR interval : tidak bisa dinilai

• Regularity : Reguler • QRS complex : tidak bisa dinilai
• Frequency : 1500/25 = 83 x/minute • Q patologi :-
• Axis : I (+), aVF (-)  LAD • LVH/RVH :- Interpretation
• Transision zone : V5 • ST segment :- • Iskemik
• P-wave : 0.04 s • T-wave : inverted lead II, III, aVF, anteroinferior
V3,V4,V5,V6
 X-RAY THORAX
PULMO
• Corakan Vaskuler Tak
Meningkat
• Tak Tampak Gambaran CTR : 3,5+6.5 X 100% = 52
Infiltrat 18

COR
• Apeks ke Laterocaudal
• Elongasi Aorta

Interpretation
DIAFRAGMA
• Diarfragma sisi kanan
tampak scalloping • Cardiomegali
• Elongasi Aorta
SUNUS
KOSTOFRENIKUS
• Tak Tampak Kelainan
 ECHO
• Dimensi ruang jantung : Tidak membesar
• Dinding LV : Menebal di PW
• Wall Motion : Global Hipokinetik
• Katup Jantung : AR Mild TR Mild MR Mild
• Fungsi LV sistolik menurun EF 38 %
• Fungsi RV sistolik baik TAPSE 17 mm
• Fungsi LV diastolik baik E/A > 1

Interpretation
• Global Hipokinetik, fungsi LV sistolik menurun
• Fungsi RV Sistolik baik, Hipertrofi PW
• AR Mild TR Mild MR Mild
pemeriksaan hasil Nilai rujukan interpretasi

Ureum 107 10-50 mg/dl H

kreatinin 2.62 0.7-1.3 mg/dl H

Interpretation

• azotemia
 ABNORMALITAS DATA
ANAMNESIS PYSHICAL EXAM LAB EXAM X-RAY THORAX

9. Dislipdemia
14. Cardiomegali
10. Hiperuricemia
15. Elongasi Aorta
11. Azotemia
4. BP : 88/55 mmHg
1. Ortopneu 5.. Takipneu ECHO
2. Cough 6.. Lung Edema
3. Smoking 7. Cardiomegali 12. Hipokinetik, Fungsi
8. Edema lower LV menurun
Extremities

ECG

13. Iskemik
Anteroinferior
 PROBLEM LIST
CHF Hipotensi Dislipedemia

1,2,3,6,7,8,12,
4 9
13,14,15

Hiperuricemia ACS CKD

10 13 11
 CHF NYHA IV IP Tx

ASSESSMENT IP Dx Non farmacology

• Low fat intake - Reduce activity
• Low salt intake - 02 Canul
Farmacology
Anatomi : • BNP(> 35) and NT-pro BNP • Furosemid 1x40 mg  reduce edem
(>125) • Bisoprolol 1x2,5 mg Beta Blocker,
- LVH • Profil Lipid Vasodilatasi
Functional : • Ureum Creatinin • Spironolacton 1 X 25 mg
- NYHA IV
Etiology :
- Hipertensi IP Mx IP Ex
Heart Disease
(HHD)
- Iskemik Heard • Bed rest/ restriction of physical activity
Diasese (IHD)
• Vital sign • Sodium and fluid restriction
• ECG • Reducing emotion stress
• Sit position or a half sleep position
 IP Tx
HIPOTENSI
ASSESSMENT IP Dx NonFarmakologi :
- O2 2-4 Lpm
Farmakologi :
• Loading RL 100-250 ml
›- • Dopamin
• Dobutamin 10 mikro/kgBB/jam .

Emergency :
Emergency IP Mx IP Ex
treatment
›Explain about Hipotensi
›Explain about treatment of Hipotensi
›Diet low salt
›Vital sign : BP ›Routine treatment
›Stay away from stress
›Increase mild exercise
 DISLIPDEMIA
ASSISMENT IP TX

High intake of cholestrol Pharmacology : Atorvastatin 1 x 20 mg

Contents
Non-Pharmacology :
Contents Lyfe style management
Explain to patients about the condition, and complication that
may occur
Exercise 60 minutes with aerobic and resistance training
IP DX
Contents
Achieve ideal body mass index and body weight
ASCVD score risk
. IP EX

IP MX Low diet of cholestrol

Eat high fiber diet and low fat
Cholesterol total, HDL, LDL,
Reduce fatty food, soda and junk food
Trigliserid
Contents
Low exercise regularly
 IP Tx
ACS Non farmacology :
Low Fat Intake
ASSESSMENT IP Dx High Fiber diet
Farmacology
Aspilet 1 x 80 mg
(maintenance)
› Mioglobin, CKMB, Troponin
CPG 1 x 75 mg (maintenance)
I, Troponin T, Profil Lipid
Fondaparinux jam 20.00 inj.
Subkutan di perut
Isosorbidinitrat 5 mg k/p (bila
1. UAP
nyeri dada
2. NSTEAMI
IP Mx IP Ex

• Reducing Emotional stress

• Reducing eat that food contain high
• EKG serial cholesterol
• Avoid smoke cigarette
TIMI SCORE
 HIPERURISEMIA

• Ass : IP MX :
- Vital sign
Etiology - Uric Acid Status
- Kidney Impaired Excretion (Insuficiency Renal)
Ip EX
- High purin intake ›Diet low purin
›Explain about Hiperurisemi
- Ekskresi disorder. ›Explain about treatment of
Hiperurisemi
• IP Dx : -
›Routine treatment
Ip Tx :
Non farmacology
• Low purin intake
Farmacology
• Allopurinol 2x100mg
 CKD
ASSESSMENT IP Dx IP Tx

Nonfarmakologi
- Sodium restriction, diuretics (sodium retention and
volume overload) 0,6-0,8 kcal/kgBB/day.
- Hemodialisa
›BGA - Ren ransplantasi
Farmakologi
- Inj. Furosemid 1 X 40 mg
- CaCO3 3x1 mg
Complication : - Na Bicarbonat 2-3 x 500 mg
- Asidosis
Metabolik IP Mx IP Ex
- Oedem Paru
›General State • Explain to the patient about the disease
›Vital Sign • Take medicine regularly
›Fluid Balance • Explain side effect of medication
›Lab : Ureum, Creatinin, Albumin
• Explain about proper daily intake,
›GFR including type of diet and food
›Urin Output
GFR Tn. AH
• GFR = (140 – umur ) x BB =
72 x kreatinin

• (140 – 78 ) x 48 = 2976 = 15.776

72 x 2.62 188.64
Thank You
THANKS!
 ANEMIA IP Tx

ASSESSMENT IP Dx Non farmacology :

-
Farmacology
› Index eritorsi Sulfas Ferrous 3 x 200 mg
› Peripheral Blood Smear Vit c 3 x 100 mg

Morphology
• Hipokrom
Mikrositer IP Mx IP Ex
• Normokrom
normositer • Bed rest/ restriction of physical
• Vital sign activity
• Hb status • Explain about Anemia
• Thrombocyte status • Explain about treatment of anemia
• Explain about side effect of
• Reaction of transfusion
anemia’s treatment