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    Case-Based Discussion: BY: DAFFA JOKO N W (30101507415) Advisor: Dr. Saugi Abduh, Sp. PD., KKV, Finasim

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    Amanullah Rayen
    Mrs. S, a 43-year-old female farmer, presented with dyspnea, leg swelling, and fatigue for 10 days. Physical examination found increased jugular venous pressure, lung edema, cardiomegaly, and leg edema. Tests showed atrial fibrillation, inferior ischemia, enlarged heart chambers, reduced left ventricular function, mitral stenosis, and pulmonary hypertension. She was diagnosed with congestive heart failure, ischemic heart disease, atrial fibrillation, valvular heart disease including severe mitral stenosis, and pulmonary hypertension.

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    Case-Based Discussion: BY: DAFFA JOKO N W (30101507415) Advisor: Dr. Saugi Abduh, Sp. PD., KKV, Finasim

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    Amanullah Rayen
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    Mrs. S, a 43-year-old female farmer, presented with dyspnea, leg swelling, and fatigue for 10 days. Physical examination found increased jugular venous pressure, lung edema, cardiomegaly, and leg edema. Tests showed atrial fibrillation, inferior ischemia, enlarged heart chambers, reduced left ventricular function, mitral stenosis, and pulmonary hypertension. She was diagnosed with congestive heart failure, ischemic heart disease, atrial fibrillation, valvular heart disease including severe mitral stenosis, and pulmonary hypertension.

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    Mrs. S, a 43-year-old female farmer, presented with dyspnea, leg swelling, and fatigue for 10 days. Physical examination found increased jugular venous pressure, lung edema, cardiomegaly, and leg edema. Tests showed atrial fibrillation, inferior ischemia, enlarged heart chambers, reduced left ventricular function, mitral stenosis, and pulmonary hypertension. She was diagnosed with congestive heart failure, ischemic heart disease, atrial fibrillation, valvular heart disease including severe mitral stenosis, and pulmonary hypertension.

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    30 views71 pages

    Case-Based Discussion: BY: DAFFA JOKO N W (30101507415) Advisor: Dr. Saugi Abduh, Sp. PD., KKV, Finasim

    Uploaded by

    Amanullah Rayen
    Mrs. S, a 43-year-old female farmer, presented with dyspnea, leg swelling, and fatigue for 10 days. Physical examination found increased jugular venous pressure, lung edema, cardiomegaly, and leg edema. Tests showed atrial fibrillation, inferior ischemia, enlarged heart chambers, reduced left ventricular function, mitral stenosis, and pulmonary hypertension. She was diagnosed with congestive heart failure, ischemic heart disease, atrial fibrillation, valvular heart disease including severe mitral stenosis, and pulmonary hypertension.

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    of 71

    CASE-BASED DISCUSSION

    BY:
    DAFFA JOKO N W (30101507415)

    ADVISOR:
    DR. SAUGI ABDUH, SP. PD., KKV, FINASIM
    PATIENT IDENTITY

     Name : Mrs. S
     Age : 43 years old
     Gender : Female
     Religion : Moeslem
     Job : Farmer
     Address : Wonosami 05/03, Banjarejo, Blora
     MR Number : 01404732
     Room : Baitulizzah 2/M2
     Entry Date : January 27, 2020
    HISTORY TAKING

     Main problem
     Dyspneu

     History of presnt illness


     Patient came to Emergency Unit of Sultan Agung Hospital with dyspneu since 10 days ago. For the first time, dyspneu
    occured while the patient was doing mild activity. She felt ortopneu and paroxismal nocturnal dyspneu. Then dyspneu
    reduced at rest. She said that her legs were swelled, abdominal enlargement without pain since 10 days ago before coming to
    hospital. She felt tired easily. Previously patients were treated Blora Hospital with the same conditions and finally referred to
    Islamic Hospital Sultan Agung Semarang. This condition was persisting until the patient came to hospital.
    HISTORY OF ILLNESS

     History of previous illness  History of family’s illness


     Asthma:  Asthma:
     Pneumonia  Pneumonia
     Arrhythmia  Arrhythmia
     Valvular heart disease:  Valvular heart disease:
     Congestive heart disease  Congestive heart disease
     Anemia:  Anemia:

     Socio-economic history:
     BPJS PBI
    SISTEMIC ANAMNESIS

    Chief Complains : Dyspneu

    Onset : 10 days ago

    Location : Chest

    Chronology : 10 days ago occured dyspneu while doing mild activity and worsten

    Quality and Quantity : patients feel dyspneu when mild activity and worsent at night and potitional changes

    Modification factor: reduce at rest.

    Comorbid complains : swelling extremities


    PHYSICAL EXAMINATION
    Interpretations: takipneu, normoweight
     General: weaknes, dyspneu
     Awareness: E4M6V5 (GCS : 15)
     Vital sign:
     Blood pressure : 102/79 mmHg
     Pulse : 51 x/mnt
     Breath frequency : 24 x/mnt
     Temp : 36,3°C
     Body mass index:
     Weight : 45 kg
     Height : 150 cm
     BMI : 20 kg/m2
    GENERAL EXAMINATION
    Interpretations: increasing JVP

     Head : msocephal
     Eyes: Anemic Conjungtiva (-/-),Icteric sclera (-/-)
     Nose : symmetric, secret (-), nostril Breath (-)
     Ears : Normal Shape, discharge (-/-)
     Esophagus : Hyperemic (-), pain devour (-)
     Mouth : Cyanosis (-), fector hepatikum (-)
     Neck : Trakhea deviation (-), Lymph Hypertropy (-), Increasing JVP 5 ± 3cm
    THORAX EXAMINATION
    INSPEKSI DEXTRA SINISTRA

    Static RR : 24x/min, Hyper pigment (-), spider nevi RR : 24x/min, Hyper pigment
    (-), atrophy Pectoral Muscle (-), ICS Normal, Diameter AP < LL (-),spider nevi (-),
    ICS Normal, Diameter AP < LL

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

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

    Percution dullness dullness

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

    Interpretations: lung edema


    CARDIAC EXAMINATION

    Inspection : Ictus cordis seen.

    Palpation : Ictus cordis is palpable at ICS VI 1 cm lateral from linea midclavicularis sinistra, thrill (+)
    with three finger, epigastric pulse (-),, sternal lift (-).

    Percussion  : dull sound


     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 parasternal line
     Lower left borderline of heart : ICS VI, mid clavicle line

    Interpretations: cardiomegaly
    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 (-)

    Interpretations: murmur
    ABDOMEN EXAMINATION

    Inspection : symetric, sycatric(-), striae(-), caput medusa (-).


    Auscultation : peristaltic (+), 20 x/mnt
    Percussion : tympani, side of dullness (+), shifting dullness (+)
    •Liver : dullness(+), right liver span 10 cm, left liver span 4 cm
    •Spleen : Throbe space percussion (+)  tympani
    Palpation
    •Superfisial : tight (-), mass (-), epigastrial pain (-)
    •Deep : epigastric pain (-), kidney, and spleen weren’t palpable, liver were palpable enlargement

    Interpretations: hepatomegaly
    EXTREMITY EXAMINATION

    Ekstremitas Superior Inferior


    • Oedema -/- +/+
    • Cold -/- -/-
    • Jaundice -/- -/-
    • Capillary 2 second 2 second

    refill

    Interpretations: oedem lower


    extremity
    LABORATORY EXAMINATION
    TEST RESULT NORMAL RESULT
    Jan 27, 2020
    HEMATOLOGY
    Interpretations:
    Hb 13,5 11.7-15.5
    • Hipokalemia
    Hematocrit 39,8 33-45
    Leukocyte 6,95 3.6-11
    Trombocyte 186 150-440
    Blood type A/+
    IMUNOLOGY
    HBsAg Non reactive Non reactive
    BLOOD CHEMICAL
    Natrium 141.1 135-147
    Kalium 3,41 3,5-5
    Chloride 102,2 95-105
    GDS 131 75-110
    Ureum 17 10-50
    Blood creatinin 0,87 0,6-1,1
    ECG Jan 28, 2020
    Interpretations:
    INTERPRETATIONS
    • Iskemia inferior
     Rhytm : ventricular
    • AF
     Regularitas : Iregular
     Frekuensi : 60 x/menit
     Axis : lead 1 = +; AvF = +  NAD
     Zona Transisi : V4
     Gelombang P : -
     Interval PR : cannot be evaluated
     Komplek QRS : 0,08 detik
     Gelombang Q : Q patologis
     Segmen ST : ST depressed in lead II, III, AVF
     Gelombang T : inverted in lead II, III, AVF,
    CHEST X-RAY
    Interpretations:
    • Kardiomegali (LV, LA, RA),
    Disertai penonjolan konus LA
    pulmonalis

    RA

    LV
    TEE
    Interpretations:
    • MR moderate
    • MS
    • LAA: trombus (+)
    ECHOCARDIOGRAPHY
    Interpretations:
    • Hipokinetik segmental
    • Fungsi LV sistolik menurun EF:
    45%
    • Dilatasi LA
    • TR moderate
    • PH moderate
    • MS severe
    • AR mild
    ABNORMAL DATA

    History Taking Physical Examination : TEE :


    17. MR moderate
    1. dsypneu, 6. Takipneu 18. MS
    2. Swelling extremities, 7. Increasing JVP 19. LAA: trombus (+)

    3. Orthopneu 8. Lung edema


    Echocardiography :
    4. Paroxysmal nocturnal 9. Cardiomegaly
    20. Hipokinetik segmental
    10. Edem extrimities 21. Fungsi LV sistolik
    dyspneu
    menurun EF: 45%
    11. Hepatomegaly
    5. Felt tired easily 22. Dilatasi LA
    23. TR moderate
    ECG : Chest X-Ray : 24. PH moderate
    Lab: 13. AF 16. Kardiomegali (LV, 25. MS severe
    14. Iskemia LA, RA), Disertai 26. AR mild
    12. Hiperglikemi inferior penonjolan konus
    15. Hipokalemi pulmonalis
    PROBLEM LIST

    Congestive Heart Failure: Pulmonal Hypertension

    Ischemic Heart Disease


    Atrial Fibrilation

    Valvular Heart Disease:


    MS severe, TR moderate, AR
    Hipokalemia
    mild
    CONGESTIVE HEART FAILURE
     Assesment
     Anatomi: Cardiomegaly (LV, LA, RA), dilatation LA
     IP Mx
     Fungsional: NYHA IV
     Vital sign
     Etiology: IHD, valvular heart disease
     ECG
     IP Dx  IP Ex
     BNP (≥ 35 pg/mL) dan Pro-BNP (≥ 125 pg/mL)
     Bed Rest/Restriction of physical activity
     IP Tx  Reducing Emotional stress
     Furosemide 3x1 amp IV (20mg/2mL) give when the sistolyc blood  Routine consumption drugs
    pressure more than 100 mmHg
     Sit position or a half sleep position
     Bisoprolol 2,5-5 mg 1x1
     Restriction fluid (max 1L/day)
     Spironolactone 25 mg 1x1
     Diviti (Low molecular weight heparin) SC 1x1
    ISCHEMIC HEART DISEASE

     IP Mx:
     Assesment
     Vital sign,
     UAP
     ECG serial
     Stable angina
     IP Ex:
     IP Dx:
     Explain about the disease
     Cardiac troponin,
     Bed rest
     Invansive coronary angiography

     IP Tx:
     Nitrocaf 2,5 mg 1x1
     Aspirin 80 mg 1x1
     Bisoprolol 2,5-5 mg 1x1
    VALVULAR HEART DISEASE

     Assessment
     Complication :  IP Mx:
     Atrial fibrillation
     Hemodynamic system
     Thromboembolism disease
     Critical limb ischemic
     IP Ex:
     ACS
     Bed rest
     IP Dx:
     Avoid heavy activities
     CHA2DS2-VASc (+2)

     IP Tx
     Repair or Replacement of valvular
    PULMONAL HIPERTENSION

     Assesment
     IP Mx:
     Cardiac : VHD
     Vital sign
     Non cardiac
     Haemodinamic system
     IP Dx:
     ECG
     Right cardiac cateterization
     IP Ex:
     IP Tx:
     Bed rest
     Pharmacological : 60 mg of diltiazem three times a day, Sildenafil 25mg 2x1
     Avoid heavy activities
     Non Pharmacological: Oxygen NRM 5L
    HYPOKALEMIA
     Assesment: -
     IP Dx: -
     IP Tx:
     Formula: Kdeficit (in mEq/ml) = (Knormal lower limit − Kmeasured) × kg body weight × 0.3

     Kdeficit (in mEq/ml) = (3,5-3,41) x 45 x 0,4

     Kdeficit (in mEq/ml) = 14,7 mEq/ml -> 15 ml KCl

     Each ml contains K 1 mEq/ml


     KSR 600 mg 1x1

     IP Mx:
     Vital sign
     ECG
     Blood Chemical

     IP Ex:
     Bed rest
    ATRIAL FIBRILATION

     Assesment
     IP Mx:
     Etiology:
     Vital sign
     Valvular heart disease
     ECG
     Non valvular
     INR (target: 2-3)
     IP Dx:
     CHA2DS2-VASc Score(2), HAS-BLED Score
     IP Ex:
     Bed Rest
     IP Tx:
     Warfarin 2 mg 1x1
     Bisoprolol 2,5-5 mg 1x1
    SOURCE
    CHF
    ISCHEMIC HEART DISEASE
    VHD
    PULMONAL HYPERTENSION
    HYPOKALEMIA
    ATRIAL FIBRILATION
    ANTICOAGULANT

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