CBD

CASE BASED DISCUSSION

Advisor : dr. H. M. Saugi Abduh, Sp.PD, KKV, FINASIM

By : Siti Mashlahatus Salamah (30101507568)
Patient Identity
 Name : Mrs. R
 Age : 32 years old
 Gender : Female
 Religion : Moslem
 Job : Housewife
 Address : Bilo RT 02/RW 01 Karangawen, Demak
 MR Number : 01337967
 Room : Baitul Izzah 2 – A7
 Entry Date : July 23 th, 2019
 History Taking
Main Problem History of Present Ilness
WEAKNESS Patient came into cardiac unit of Sultan Agung Islamic
Hospital Semarang on july 23th 2019, because she feel
weakness. She has been experiencing this complain
since one week before she came to the hospital. it felt
continuously, getting worse when she is working and will
be improve with a rest. She also complained nausea
and vomiting, swelling on both of her legs and
sometimes feel dispnea. She has history of CHF, CKD
and post surgery of cholelitiasis one year ago.
 Systematic Anamnesis 25 / 7 / 2019

Main Problem Main Complains: Weakness

WEAKNESS Onset: While she working and rest

Quality and Quantity: Patient complained the weakness

continously, occured while she working and not feeling better
while she took a rest.

Chronology: A weakness started since while she was working

and not feeling better after took some rest, then she came to
hospital.

Modification factor: There is no modification factor.

Comorbid complains: Swelling in the feet

History of Illness
History of Previous Family History Socio-Economic
Illness History

• Hypertension (-) • Hypertension • Hospital cost certified

• DM (-) history (-) by “BPJS-PBI”
• CHF (+) • DM history (-)
• CKD (+) • CHF (-)
• CKD (-)
Physical Examination
 General Status
• General : Weakness
• Awareness : Composmentis (GCS 15)
• Antropometric Status
• Weight : 50 kg
• Height : 155 cm
• BMI : 20,8
Vital Sign
•BP : 130/90 mmHg
•HR : 98 x /minute
•RR : 20 x /minute
Intrerpretation: Intrerpretation:
•Temp : 36,5⁰C Normal Normoweight
 General Status
Anemic conjuntiva (+/+) • • Mesocephal (+)
Icteric sclera (-/-) • • Alopesia (-)
• Rambut jagung (-)
Symmetric •
Secret (-) • • Normal shape
• Discharge (-/-)
Nostril Breath (-) •
• Skin jaundice (-)
Cyanosis (-) • • Pale (+)
dry lips (-) • • Hiperpigmentasi (-)
snoring (-) •

Tracheal deviation (-) • • Oedem extremity inferior (+/+)

Lymph hypertrophy (-) • • Cold extremities (-)
Increasing JVP (+) •
Intrerpretation:
Pale, Anemic conjungtiva, increasing JVP,
Oedem extremity inferior
 Lung Examination Intrerpretation:
Ronchi Basal (+)
Anterior Posterior
Inspection RR : 20x/min, Hyper pigment (-), spider nevi (-), RR : 20x/min, Hyper pigment (-), spider nevi
Static
atrophy Pectoral Muscle (-), Hemithoraks S=D, (-), atrophy Pectoral Muscle (-), Hemithoraks S=D,
ICS Wider, Diameter AP < LL ICS Wider, Diameter AP < LL

Inspection Up and down of hemitoraks S=D, Up and down of hemitoraks S<D, abdominothorakal
Dinamic
abdominothorakal breathing (+), muscle breathing (+), muscle retraction of breathing (-),
retraction of breathing (-), retraction ICS (-) retraction ICS (-)

Palpation Palpable pain(-), tumor (-), Arcus costae angle < alpable pain(-), tumor (-), Arcus costae angle < 900,
900, wider of ICS (-), Chest Expantion simetris, wider of ICS (-), Chest Expantion simetris, Stem
Stem fremitus S=D fremitus S=D

Percusion Flat/dullness Flat/dullness

Auscultation Ronchi (+) basal Ronchi (+) basal

 Cardiac Examination
Inspeksi Ictus cordis isn’t seen

Palpation thrill (-), epigastric pulse (-), parasternal pulse (-), sternal lift (-).

Percussion - 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 sternal line
- Lower left borderline of heart : ICS VI, 3 CM lateral from left mid clavicle line
Auscultation
Aorta valve : S1 & Pulmonary valve :
S2 standart, S1 & S2 standart,
additional sound (-) additional sound (-)

Pulmonary valve : Pulmonary valve :

S1 & S2 standart, S1 & S2 standart,
additional sound (-) additional sound (-)

Intrerpretation:
Cardiomegaly
 Abdominal Examination
Bulging(-), Hyperpigmentation (-), Sycatric(-), Striae(-), Vein Distention (-), Caput Medusa
Inspeksi
(-)
Auscultation Peristaltic (+) Normal ( 22 x / minute )

• Hypertimpani (-), side of deaf (-), shifting dullness (-)

Percussion • Liver : dullness (+), right liver span 14 cm, left liver span 10 cm
• Spleen : Traube space percussion (+)

• Superfisial : tight (-), mass (-), epigastrial pain (-)

Palpation
• Deep : abdominal pain (-), liver (-) and spleen palpable (-) renal (-) Murphy’s sign (-)

Intrerpretation:
Hepatomegaly
Laboratorium
 Hematology
July, 23th 2019
Hematology Result Normal

Hemoglobin 7,0 (L) 11,7 – 15,5 g/dl

Hematokrit 20,7 (L) 33 – 45 %

Leukosit 9,82 3,6 – 11,0 Ribu/uL

Trombosit 297 150 – 440 Ribu/uL

Golongan Darah A / Positif -

Intrerpretation:
•Anemia
 Kimia July, 23th 2019
Kimia Result Normal
Ureum 73 (H) 10 – 50 mg/dl

Blood Creatinin 1,90 (H) 0,6 – 1,1 mg/dl

Intrerpretation:
Protein total 4,05 (L) 6,0 – 8,0 g/dl
Hiperuremia
Albumin 1,44 (L) 3,4 – 4,8 g/dl Hipercreatinin
Hipoprotein
Globulin 2,61 g/dl
Hipoalbumin
Natrium 145,2 135 – 147 mmol/L Hiperchloride
hipocalsemi
Kalium 3,62 3,5 – 5 mmol/L

Chloride 114,0 (H) 95 – 105 mmol/L

Calcium 6,8 (L) 8,8 – 10,8 mg/ dl

 Hematology July, 25th 2019
Hematology Result Normal

Hemoglobin 10,1 (L) 11,7 – 15,5 g/dl

Hematokrit 30,1 (L) 33 – 45 %

Leukosit 12,74 (H) 3,6 – 11,0 Ribu/uL

Trombosit 340 150 – 440 Ribu/uL

Kimia
Kimia Result Normal Intrerpretation:
Albumin 1,44 (L) 3,4 – 4,8 g/dl •Anemia
•Leukositosis
Esbach •Hipoalbumin
0,1 (H) <0,05 % gr/l
Protein
•proteinuria
 Kimia July, 27th 2019
Kimia Result Normal Intrerpretation:
Albumin 1,91 (L) 3,4 – 4,8 g/dl •Hipoalbumin
•Hipocalsemi
Calcium 7,5 (L) 8,8 – 10,8 mg/dL

July, 28th 2019

Kimia Result Normal
Intrerpretation:
Albumin 2,12 (L) 3,4 – 4,8 g/dl •Hipoalbumin

Kimia July, 30th 2019

Kimia Result Normal
Natrium 145,2 135 – 147 mmol/L Intrerpretation:
•Hipochloride
Kalium 3,40 (L) 3,5 – 5 mmol/L
•Hipocalsemi
Chloride 113,5 (H) 95 – 105 mmol/L

Calcium 8,0 (L) 8,8 – 10,8 mg/ dl

ECG July, 23th 2019
 Interpretation
• Rhytm : Sinus
• Regularitas : Regular
• Frekuensi : 88 (1500/17)
• Axis : NAD (LI +, aVf +)
• Zona Transisi :-
• Gelombang P : 0.08 dtk (normal)
• Interval PR : 0.12 (normal)
• Komplek QRS : 0.8 (normal)
• Gelombang Q : normal
• Segmen ST : normal
• Gelombang T : normal

Interpretasi: Sinus rythm

 X-Ray
COR
•CTR > 0,5 cm (0,7 cm)
•Kardiomegali (LV,LA) disertai
Elongatio Aorta

PULMO
•Normal

Interpretasi:
Cardiomegaly

August, 1th 2018

Echocardiography
Interpretation
Echocardiography
Interpretation

HISTORY TAKING
1. Weakness
2. Nausea and vomiting
3. Swelling low extremity
4. Dyspnea
PHYSICAL EXAMINATION
5. Skin pale
6. Anemic Conjunctiva
7. Increasing JVP
8. Oedem extremity inferior
9. Lung : ronchi
10. Cardiac : Cardiomegaly
11. Hepatomegaly
Abnormal Data
X-RAY
21. Cardiomegaly (LV,LA)
LABORATORIUM
12. Anemia
13. Leukositosis
14. Uremia
15. Hipercreatinin
16. Hipoprotein
17. Hipoalbumin Echocardiography
18. Proteinuria 22. LVH
19. Hiperchloride 23. Efusi pericard
20. Hipokalsemia 24. LA dilatation
25. Insuficiency renal
 Problem List

CHF
Syndrom Nefrotik CKD
1,3,4,7,8,9,10,11,21,
3,8,14,15,16,17,18, 2,3,8,14,15,16,17,18,
22,23,24
20,25

Anemia Hipoalbumin Hipokalsemia

1,5,6,12 15,16,17 19
THANK YOU