CASE BASED DISCUSSION

A 75 years old woman with dyspneu

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

Penyusun:
BINTANG BOLYVIANTO ARGAWAN
012116350
IDENTITAS PASIEN
Name : Mrs. N

Age : 75 years old

Gender : Female

Religion : Moslem

Job : A housewife

Address : Grojokan RT.02/RW.05 Jaten, Juwiring, Klaten

MR number : 01347713

Room : Baitul Izzah 1 – K2

Entry date : June 6th, 2018

Date of passed away : June 10th, 2018

HISTORY TAKING
Patient Problem: abnormal
breathing (dyspneu)
History of Present Illness:

Patient was borrowed into the emergency department of Sultan

Agung Islamic Hospital Semarang complained about her
abnormal breathing (dyspneu). It started 2 weeks before came to
RSISA and getting worst in this 3 days, especially when did an
activity and getting well when take a rest. And when she was
hospitalized she starts getting ortopneu and not better when
take a rest. She also complained epigastric pain and cold sweat.
HISTORY OF ILLNESS
HISTORY OF PREVIOUS ILLNESS
• Hipertensi history 1 year

• Dyspepsia (-)

• Heart dissease history (-)

• Atsma history (-)

• Alergy history (-)

FAMILY’S HISTORY OF DISEASE
• Hipertensi history (-)

• Diabetes Mellitus (-)

• Heart dissease (-)

• Atsma history (-)

HISTORY OF HABBIT
smoke
• negatif

alcohol
• negatif

exercise
• rare

sugar
• rare

Salty food
• She like
SOSIO-ECONOMIC HISTORY

Patient use asurancy BPJS

SISTEMIC ANAMNESIS
Main Complains : Dyspneu
Onset : 2 weeks before came to
hospital
Location : Chest
Chronology : She complained that 2 weeks
about her dyspneu. her hartburn is pain when she
works.
Quality and Quantity : patients feel dyspneu when
activity
Modification factor : rest condition
Comorbid complains : epigastric pain and cold sweat
 ANAMNESIS SISTEMIK
SISTEM NEUROPSIKIATRI
Kejang (-), gelisah (-),
kesemutan (-), mengigau (-),
SISTEM RESPIRASI emosi tidak stabil (-)
Sesak nafas (+), batuk
EKSTREMITAS ATAS
(-), tidur mendengkur (-)
Luka (-), kesemutan(-), bengkak(-), sakit
sendi (-), panas (-), berkeringat (+),warna
merah pada telapak tangan (-)

SISTEM KARDIOVASKULAR
Sesak nafas saat berbaring
(-), nyeri dada SISTEM MUSKULOSKLELET
(+), berdebar-debar (-), Nyeri otot (-), nyeri sendi (-
keringat dingin (+) ), kaku otot (-)

SISTEM GI
SISTEM GENITOURIN
Mual (-), muntah (-), perut mules
Sering kencing (-), kencing berkurang
(-), diare (-), nyeri ulu hati (+),
dan sedikit – sedikit (-), nyeri saat
nafsu makan menurun (-), BAB (-)
kencing (-), keluar darah (-), berpasir (-
), kencing nanah (-), sulit memulai
EKSTREMITAS BAWAH kencing (-), warna kencing kuning
Luka (-), gemetar (-), ujung jari jernih, anyang-anyangan (-), berwarna
dingin (-), kesemutan di kaki (-), seperti teh (-).
sakit sendi (-), bengkak (+) kedua
kaki
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
weakness Compos mentis BB : 54 Kg
BP : 149/81mmHg
GCS E4M6V5 TB : 1,58 m
HR : 88x/ment,
BMI : 22 RR : 34x/menit,
(normoweight) Temperatur :

Nutritional Status
General

awarness

Vital Sign
36,9°C
Head • mesochepal,

Eye • blurred vision (-), red eyes (-), icteric sclera (-/-)

Nose • nosebleed (-), discharge (-), nostril breath (-)

Mouth • cyanosis (-), thrush (-), bleeding gums (-)

Ear • hearing loss (-), ring (-), discharge (-)

Skin • itching (-), redness (-), jaundice (-), pale (-), slick (-),
 Inspeksi
• Ictus cordis (-)
THORAX : COR
Palapsi

• thrill (-), epigastric pulse (-), parasternal pulse (-),

sternal lift (-).

Perkusi

• Upper borderline: ICS II left parasternal line

• Waist : ICS III left parasternal line
• Lower right borderline : ICS IV right sternal line 1cm shift to medial
• Lower left borderline : ICS V from left midclavicula line 1cm shift to lateral

Auskultasi
• S I and S II standar, reguler in every valve
• Additional sound gallop (-), murmur (-)
Intepretation kardiomegali
 INSPEKSI ANTERIOR POSTERIOR

Static RR : 22/min, Hyper pigment (-), spider nevi RR : 22/min, Hyper pigment
(-), atrophy Pectoral Muscle (-), Hemithoraks D=S, ICS Normal, Diameter (-),spider nevi (-), Hemithoraks D=S, THORAX : PULMO
AP < LL ICS Normal, Diameter AP < LL

Dynamic Up and down of hemitoraks D=S, abdominothorakal breathing, (-), Up and down of hemitoraks D=S,
muscle retraction of breathing (-), abdominothorakal breathing (-),
retraction ICS (-) muscle retraction of breathing(-),
retraction ICS (-)

Palpation Palpable pain(-), tumor (-), Arcus costae angle < 900, enlargement of ICS Palpable pain (-), tumor (-),
(-), Stem fremitus normal Stem fremitus normal

Percution sonor sonor

Auskultation Vesicular (-), Whezzing (-), Ronchi (-) Vesicular (-), Whezzing (-), Ronchi (-)

Intepretation : normal
 Inspeksi
• symetric, sycatric (-), striae (-),enlargement of vena (-),
caput medusa (-), plakat eritematous with soft skuama (-)
ABDOMEN
Auskultasi
• peristaltic (+), 10 x/ menit
• Superfisial : tight (-), mass (-)
• Deep : abdominal pain (-), liver, kidney, and spleen weren’t
palpable, Murphy’s sign (-)
Perkusi
• timpani pada seluruh lapang abdomen, pekak sisi (-),
pekak alih (-).

Palpasi
• tympani, side of deaf (-), shifting dullness (-), pain in epigastric (+)
Liver : deaf (+), right liver span 11 cm, left liver span 6 cm
Spleen :Throbe space percussion (+)  tympani Intepretation : palpation pain in
epigastric
EKSTREMITAS
Ekstremitas Superior Inferior

• Oedema -/- +/+

• Cold -/- -/-

• Jaundice -/- -/-

Interpretation : Oedem Etremitas

Inferior
LAB EXAMINATION
Examination ( 06/06/2018) Result

Ureum 49

Creatinin 1,25 H

Natrium 136,7

Kalium 3,33 L

Chloride 99,3

High Sensitive Troponin I 93,5

Interpretation : Azotemia,
Hipokalium
Examination ( 06/06/2018) Result

Hemoglobin 12,3

Hematokrit 40,1

Leukosit 6,77

Trombosit 215

Golongan Darah/Rh B/ Positif

Interpretation : Normal
Examination ( 08/06/2018) Result

Cholesterol 133

Trigliserid 69

HDL Cholesterol Direct 19 L

LDL Cholesterol Direct 106

Urid Acid 10,7 H

Interpretation : Hiperuricemia
 Intepretation :
COR :

X-RAY THORAX CTR > 50%

Apeks bergeser ke laterocaudal.
Pinggang jantung mendatar.
Elevasi main bronkus kiri
Batas kanan jantung bergeser ke lateral
Elongasio aorta
Kalsifikasi arcus aorta
PULMO:
Corakan bronkovaskuler norma
Tak tampak bercak pada kedua paru

Diafragma dan sinus kostofrenikus kanan

baik, kiri superposisi dengan jantung

KESAN :

COR : KARDIOMEGALI (LV, LA, RA)

ELONGASIO AORTA & KALSIFIKASI

ARKUS AORTA

PULMO: TAK TAMPAK KELAINAN

ECG
INTERPRESTASI
Rytme : Sinus
Regularitas : Reguler
Frekuensi : Normal
Axis : NAD
Zona Transisi : Tidak dapat dinilai
Gelombang p : Normal
Interval PR : Normal
Komplek QRS : Normal
Gelombang Q : Normal
Segmen ST : ST depresi downsloping (V5, V6)
Gelombang T : Normal

Kesan : NSTEMI, LBBB

ECHOCARDIOGRAPHY
ABNORMAL DATA
 ANAMNESIS Phisical Examination Supporting Examination
1. Dyspneu 6. Percussion of cor 10. Creatinin ↑ 13. X-Thorax 
2. Ortopneu 7. Palpation of abdomen 11. Kalium Cor : kardiomegali,
3. Cold sweat 8. Etremity inferior oedem 12. Urid Acid ↑ elongasio aorta,
4. Epigastric pain 9. BP : 149/81 mmHg kalsifikasi arcus aorta
5. Hypertension history 14. ECG :
(from 1 years ago) 15. Echo : Global
hipokinetik, LV+RV
sistolik function
decreased, ralaation
disturbance of
diastolik LV function,
MR Moderate, TR
Severe
PROBLEM LIST
1. CHF 1, 2, 3, 5, 6, 8, 9, 13, 15
2. Hypertension gr I 5, 9
3. Azotemia 10
4. Hipokalemia 11
5. Hiperuricemia 12
PROBLEM SOLVING
 CHF
1. Assessment :
4. Initial Plan of Monitoring
functional: NYHA IV
anatomi: LA & LV dilatation Vital sign, ECG, Foto Rontgen
etiologi: HHD
5. Initial Plan of Education :
1. Initial Plan of Diagnosis :
 Bed Rest/Restriction of physical activity
-  Reducing Emotional stress
3. Initial Plan of Therapy  Routine consumption drugs
Pharmacology  Fluid restriction (1,5 L-2L/day)
• Inj.Furosemid 20mg/ml 2 Amp x 1  Monitoring weight loss independen >2kg
• Captopril 3x12,5mg for 3 days increase dose diuretik
• Bisoprolol 1x1,25 mg po
• Spironolacton 25 mg 1x1
 HT GRADE I 4. Initial Plan of Monitoring
1. Assessment
• Vital Sign
▪ Risk factor cardiovasculer
2. Initial Plan of Diagnosis : 5. Initial Plan of Education :
▪ Waist circumference, ABPI • Explain to patients about the
3. Initial Plan of Therapy condition
a. Non Pharmacology • Controlling dietary habits
• Reduce salt intake
▪ Lowering salt intake on 5 g/day of NaCl
• Reduce fluid intake (1,5 L-2L/day)
▪ Dietary approaches to stop hipertension (DASH). Include
• Take medication regulary
compsumption of fruits , vegetables, low fat milk
• High consumption vegetables and
saturated.
fruit and low fat
▪ lifestyle .
b. Pharmacology
• Captopril 12,5 mg 3x1
AZOTEMIA
Ass : insufisiensi renal
IP Dx : Check GFR , Mikral Test, USG
Ip Tx :
• Non pharmacology
diet low in protein and limiting comsumtion salt
control blood pressure (inhibit progressivity)

Pharmacology : beta blocker, diuretics

Ip Mx : Vital Sign, GFR, awareness, fluid balance, re-check ureum and blood creatinin

IpEx :
• Do not do heavy activity
• Sufficient rest and take medication regularly
• Explain about proper daily intake, including type of diet and food
• Routine Control of Blood Pressure
 Hipokalemia
• Ass : Aritmia
• IP Dx : EKG
• IP Tx :
• Non Pharmacology
• Diet tinggi kalium (Pisang, Anggur, Alpukat, Kacang-
kacangan, Kentang)
• Pharmacology :
• Suplemen Kalium (Aspar-K)  target Kalium 4 mg/dL (1 flash
20 mcq dilarutkan dalam 100 ml)
• IP Mx :
• Monitoring Kalium
• EKG
• IP Ex :
• Konsumsi makanan yang tinggi kalium
Rumus perhitungan kalium :
(4-kalium) x BB x 0,3 =
(4 - 3,33) x 54 x 0,3 = 10,85
HIPERURICEMIA
Assassement:
etiology : high intake, excretion disorder

IP Dx : kidney usg
IP Tx :
Pharmacologic
Allopurinol 300 mg 1x1
IP Mx:
Uric Acid
IP Ex:
Avoid Organ meats high in purine
Avoid sweetened soda beverage
 VHD
1. Assessment :
- Tromboembolism disease 4. Initial Plan of Monitoring :
▪ INR
2. Initial Plan of Diagnosis :
Oral anticoagulant (warfarin 2 mg) 5. Initial Plan of Education :
▪ Reduced Activity
3. Initial Plan of Therapy ▪ Education of diseases
• monitoring
TERIMAKASIH

CHF
HT GRADE I
AZOTEMIA
Laju Filtrasi Glomerulus (LFG) :
140−𝑈𝑚𝑢𝑟 𝑥𝐵𝐵 (𝑘𝑔)
= 𝑚𝑔
72𝑥𝑠𝑒𝑟𝑢𝑚 𝑘𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛( )
𝑑𝐿

= (140-75) x 54 x0,85
72 x 1,25
Chronic Kidney
= 33,15
Disease Grade IIIb
 Kriteria CKD (terjadi lebih dari 3 bulan)
Penanda kerusakan ginjal (1 atau - Albuminuria (AER ≥ 30mg/24 jam;
lebih) ACR ≥ 30mg/g (≥3 mg/mmol)
- Abnormalitas sedimen urin
- Abnormalitas elektrolit atau lainnya
yang berkaitan dengan gangguan
tubulus
- Abnormalitas struktur yang
dideteksi dari radiologi
- Riwayat transplantasi ginjal
Penurunan laju filtrasi glomerulus (GFR) GFR < 60 ml/menit/1,73 m2
Old Classification of CKD as Defined by Kidney Disease Outcomes Quality Initiative (KDOQI)
Modified and Endorsed by KDIGO

Stage Description Classification Classification

by Severity by Treatment
1 Kidney damage with GFR ≥ 90
normal or increased GFR
2 Kidney damage with GFR of 60-89 T if kidney
mild decrease in GFR transplant

3 Moderate decrease in GFR GFR of 30-59 recipient

4 Severe decrease in GFR GFR of 15-29 D if dialysis

5 Kidney failure GFR < 15 D if dialysis

Note: GFR is given in mL/min/1.732 m²

KDIGO, Kidney
National Kidney Foundation. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Disease: Increasing
Evaluation, Classification, and Stratification. Am J Kidney Dis 2002;39(suppl 1):S1-S266 Global Outcomes
56
RENCANA TATALAKSANA PENYAKIT GINJAL KRONIK SESUAI DENGAN
DERAJATNYA (SUDOYO, 2014)

Derajat LFG (mlmnt/1.73 m2) Rencana tatalaksana

1 ≥ 90 Terapi penyakit dasar, kondisi komorbid,
evaluasi perburukan (progression) fungsi
ginjal, memperkecil risiko kardiovaskuler

2 60-89 Menghambat perburukan (progression)

fungsi ginjal

3 30-59 Evaluasi dan terapi komplikasi

4 15-29 Persiapan untuk terapi pengganti ginjal
5 <15 Terapi pengganti ginjal
 Kidney Disease: Improving Global Outcomes
(KDIGO) CKD Work Group. Kidney Int Suppls.
2013;3:1-150.
 INDIKASI HEMODIALISA
Hemodialisis segera atau Hemodialisis kronik, yaitu
emergency hemodialisis yang dilakukan
seumur hidup
• Uremia ( BUN >150mg/dL) • Dimulai apabila dijumpai
• Oliguria (urin < salah satu gejala yaitu :
200ml/12jam) • a. LFG < 15ml/menit,
• Anuria (urin < 50ml/ 12jam) tergantung gejala klinis
• Asidosis berat (pH < 7.1) penderita
• Hiperkalemia • b. Malnutrisi atau hilangnya
• Ensefalopati uremikum massa otot
• Neuropati Uremikum • c. Gejala uremia antara lain
anoreksia, mual muntah,
• Hipertermia lethargy
• Disnatremia (Natrium > 160 • d. Hipertensi yang susah
atau < 115 mmol/L) dikontrol
• e. Kelebihan cairan
KOMPLIKASI

62
HIPOKALEMIA
Hypokalemia was defined as K+ level <3.2 mEq/L.
Patients were classified into 3 groups based on K+levels:
(1) Mild/grade 1 (3.0–3.2 mEq/L),
(2) Moderate/grade 3 (2.5–2.9 mEq/L),
(3) Severe/grade 4 (<2.5 mEq/L).
 HIPERURICEMIA
Assassement:
etiology : high intake, excretion disorder

IP Dx : kidney usg
IP Tx :
Pharmacologic
Allopurinol 100 mg 1x1
IP Mx:
Uric Acid
IP Ex:
Avoid Organ meats high in purine
Avoid sweetened soda beverage
Do Excercise
VHD