Case Based Discussion (CBD)

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

Presented by :
Andalisa Dewi Permata Sari
30101206563
Department of Internal Medicine
Medical School of Sultan Agung Islamic University
2017
 Patient`s Identity
Name : Mr. N
Age : 55 years old
Sex : Male
Religion : Moslem
Job :-
No. MR : 01195219
Address : Genuksari RT 06 RW 06 Genuk
Semarang
Room Care: Baitul Izzah 1
Date in : Oktober 4th 2017
Date out : Oktober 8th 2017
Status Care: JKN non PBI grade III
 HISTORY TAKING

Main Dyspneu
Problem

Patient came into the emergency department of

History of Islamic Hospital of Sultan Agung Semarang
Present complained about his abnormal breathing (dyspneu).
Illness
Its started 7 days ago when do activity. Patient usually
wake up in the midnight when he felt dyspneu.
Patient need more pillows when slept to decrease his
dispneu. Patients family also complained sometimes
he had abnormal breathing (dyspneu) when he felt
tired. Patients also complained chest pain.
 HISTORY TAKING (cont)
History of previous disease
Hipertension (+)
Heart disease history (+)
Asma (-)
DM (-)
Maag (-)
Allergy (-)
Smoking (+)

Familys history of disease

Hipertension (-)
DM (-)
Asma (-)

Sosio-Economic History :
Hospital cost certified by JKN- PBI
 SISTEMIC ANAMNESIS
Main Complains : dyspneu

Onset : 7 days ago

Location : chest

Quality and Quantity : patient feel dsypneu when activity.

Patient usually wake up in the midnight when he felt

dyspneu.

Chronology : He complain that 7 days ago, he feel hard to breath

when he activity and when he felt tired.

Modification factor : he felt better when break the activity and slept to
decrease his dispneu

Comorbid complains : chest pain

GENERAL STATUS
BMI (Body Mass Indeks)
Weight : 60 kg BMI = 60: (1,68 x 1,68) = 22,03 kg/m2
High : 165 cm

Intepretation :
Normoweight

General : weak
Awareness : Composmentis (GCS 15)
Vital Sign

Blood Pressure : 140/90 mmHg

Heart rate : 86 x/minute

Breath Frequency : 24 x/minute

Temp : 36,7oC Intepretation :

Hypertention grade I
 PHYSICAL EXAMINATION
General : dyspneu
Skin : plakat (-) eritematous (-),
Head : headache (-)
Eyes : blurred vision (-), red eyes (-), icteric sclera (-/-)
Ears : hearing loss (-), ring (-), discharge (-)
Nose : nosebleed (-), discharge (-)
Mouth : cyanosis (-), thrush (-), bleeding gums (-)
Throat : pain swallow(-), hoarseness (-), odinofagia (-)
Neck : enlargement of the gland (-), JVP (-)
Chest : cough (-), sputum (-), blood (-)
Cardiac : chest pain (+)
Digestive : abdominal pain (-), nausea (-), vomiting (-)
Musculoskeletal : rigid (-), back pain (-)
Extremity : oedem extremity (-)
 Intepretation :
LUNG EXAMINATION dullness on the right
side of the lung
INSPEKSI ANTERIOR POSTERIOR

Static RR : 24x/min, Hyperpigment (-), spider nevi RR : 24x/min, Hyperpigment

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

Percution dullness (+) dullness (+)

Auskultation Vesicular (+), Whezzing (-), Ronchi (+) Vesicular (+), Whezzing (-),
Ronchi (+)
 CARDIAC EXAMINATION
Inspection : Ictus cordis is seen.

Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-),

sternal lift (-).

Percussion : dull sound

Upper borderline of heart
Waist of heart
Lower right borderline of heart
Lower left borderline of heart
clavicle line
: ICS II left sternal line
: ICS III left parastern line
: ICS V right sternal line
: ICS VI, 2 cm lateral from left mid
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 (-).
Auscultation : peristaltic (+)
Palpation :
Superfisial: tight (-), mass (-), epigastrial pain (-)
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 7 cm
Spleen : Throbe space percussion (+) tympani
Intepretation :
normal
EXTREMITY EXAMINATION
Ekstremitas Superior Inferior

Oedema -/- -/-

Cold -/- -/-

Jaundice -/- -/-

Intepretation : normal
Lab. EXAMINATION
Examination Result
(04/10/2017)
Gula Darah 145
Sewaktu

Intepretation :

Leukositosis
Azotemia
04/10/17 ECG

Intepretation :
Iskemia Inferior
04/10/17 ECG

IRAMA : Sinus rhytm

REGULARITAS : Regular p-p: regular, r-r: regular
FREKUENSI : 300:3= 100 x/menit
AXIS : L1 (+) AVF (+) Normo Axis Deviation
ZONA TRANSISI :-
GELOMBANG P : 0,08 s
PR INTERVAL : 0,16 s
QRS COMPLEX : 0,06 s
ST SEGMEN : ST elevasi (-), ST depresi (-)
GELOMBANG T : T inverted di lead II, III, Avf
X-RAY THORAX

COR : CTR > 50 %. Apeks bergeser ke laterokaudal.

Elongasi Aorta
PULMO:
Corakan bronkovaskular meningkat, disertai blurring vasculer
Tampak bercak pada perihiler dan parakardial kanan kiri.
Tampak kesuraman homogen pada laterobasal hemithorax
kanan.
Diafragma kanan setinggi costa v 10, sinus kostofrenikus
kanan tumpul, kiri baik.
KESAN :
COR : CARDIOMEGALI (LV)
ELONGASI AORTA
PULMO: EDEM PULMO
EFUSI PLEURA KANAN
ECHO
ECHO
 Dimensi ruang jantung : membesar di LV
Dinding LV : menebal di IVS+PW
Wall Motion : Global Normokinetik
Katup jantung : MR moderet, TR mild
Fungsi LV Sistolik menurun, EF 13%
Fungsi RV Sistolik Baik, TAPSE 21mm

KESAN :

Global Hipocinetic

Decreasing LV sistolic function

Normal RV sistolic function,

MR moderet TR mild

PH mild

Dilatation LV

SPECC ++
 Data Abnormality
Physical Examination
5. Hypertention grade I ECG
Cor 10. Iskemia Inferior
6.Cardiomegali Lab Chemistry
History Taking
Pulmo 11. Leukositosis
1.Dyspneu deffort 12. Azotemia
7. Stem fremitus deacresed
2.Orthopneu
8. Dullness
3.Chest pain
9. Ronchi (+)

ECHO
Radiology
17. Decreasing LV sistolic function
Examination Normal RV sistolic function
Ro Thoraks : 18. Global hipokinetik
13. Cardiomegali (LV)
19. MR moderet
14. Elongasi aorta
20. TR mild PH mild
15. Oedem pulmo
21. Dilatation LV
16. Efusi pleura
 PROBLEM LIST
1 2 3
CHF NYHA 4 CAD VHD
(1,2,3,6,7,8,9,13, (3,10, 18) (19)
15,16,21)

4 5 6
HHD EFUSI AZOTEMIA
(5,14,21) PLEURA(7,8,9, (12)
16)
1. CHF NYHA 4
Ass:
Etiologi : CAD, VHD
Anatomi : LVH
Fungsional : NYHA IV

IP Dx : - BNP dan Pro-BNP, angiography

IP Tx :

Non Pharmacology

Low Salt intake

Reduce activity

High fiber Diet

 Pharmacology

Furosemide 20 mg 2x1

Captopril 6,25 mg 1x1

Carvedilol 6,25 mg 1x1

Spironolakton 25 mg 1x1

Lactulosa Syr 1x1

Ip. Mx : Vital sign, ECG

Ip. EX :
Bed Rest/Restriction of physical activity
Reducing Emotional stress
Sit position or a half sleep position
High fiber Diet
2. SKA
Ass:
- unstable angina, (GRACE Score = 119 (intermediate risk), CRUSADE
Score = 55 (High risk)
- NSTEMI
IP Dx : Coronary angiography, cardiac marker,
IP Tx :
Non Pharmacology

PCI

Pharmacology

ISDN subl. 5 mg 3x1

Aspilet 80 mg 1x1

Clopidogrel 75 mg 1x1

Nitrokaf 2,5 mg 2x1

 GRACE RISK SCORE
Age ( Years ) Point Heart Rate Creatinin (mg/dl)
< 40 0 < 70 0 0,0 0,39 2
40 49 8 70 89 7 0,4 0,79 5
50 59 36 90 109 13 0,8 1,19 8
60 69 55 110 149 23 1,2 1,59 11
70 79 73 150 199 36 1,6 1,99 14
> 80 91 > 200 46 0,2 3,99 23
Systolic BP (mmHg ) Killip class >4 31
< 80 63 Class I 0
80 99 58 Class II 20
Total possible score is 258
100 119 47 Class III 39
120 139 37 Class IV 59
140 159 26 Cardiac arrest at admission 43
160 199 11 Elevated cardiac marker 15
> 200 0 ST segmen deviation 30
 HIGH RISK VERY HIGH RISK
Relevant rise or fall in troponin
Dynamic ST- or T-wave changes Haemodynamic instability or
(symptomatic or silent) cardiogenic shock
GRACE Score > 140 Recurrent or ongoing chest pain
refractory to medical treatment
Life-threatening arrhythmias or
cardiac arrest
Intermediete RISK
Diabetes mellitus Mechanical complications of MI
Renal insufficiency Acute heart failure
(eGFR <60 mL/min/1.73 m) Recurrent dynamic ST-T wave
LVEF < 40% or congestive HF changes, particularly with
Early post infarction angina intermittent ST-elevation
Prior PCI
Prior CABG
GRACE risk score 109 - 140

Roffi M et al. European Heart Journal 2015. doi:10.1093/eurheartj/ehv320

 Bleeding risk score CRUSADE SCORE

Very low < 20 ; low (2130) ; moderate (31 40);

high (4150); very high (50)

Hamm CW et al. Eur Heart J 2011;32:2999 3054

IP Mx: vital sign

IP Ex:
Bed Rest/Restriction of physical activity
Reduce fatty food
Reducing Emotional stress
Control blood pressure
Routine consumption drugs
3. VHD
Ass: MR moderat = to prevent thromboembolisme

IP Dx : -
IP Tx :
Non Pharmacology :
Repair of valvular ( consul to BTKV)
Pharmacology :
Warfarin 5 mg /day
IP Mx:
Monitoring hemodynamic system, INR (2-3)

IP Ex:
- Education of disease
- Reduce activity
4. HHD

Ass : Benigna
Maligna

IP Dx : Funduskopi

IP Tx :
Non Pharmacology

Low Salt intake

Reduce activity

Pharmacology : Captopril 6,25 mg 1x1

Carvedilol 6,25 mg 1x1

IP Mx: Vital Sign

IP Ex:
Stop smoking
Diet kolesterol

Diet low salt

Routine consumption drugs

5. EFUSI PLEURA

Ass : transudates
exudates

IP Dx : Rivalta test

IP Tx :
Principal theraphy underlying disease treatment
Non Pharmacology : O2 canule 3L/minutes

IP Mx : Vital sign

IP Ex : Reduce activity
6. AZOTEMIA

Ass : insufisiensi renal

IP Dx : Check GFR, kidney usg
Ip Tx : principal theraphy inhibit progresivitas
Non pharmacology
diet low in protein and limiting comsumtion salt
control blood pressure

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

and blood creatinin

IpEx :
Reduce activity
Sufficient rest and take medication regularly
Explain about proper daily intake, including type of diet and food
 GRACE REGISTRY
STEMI Higher mortality 6
months after
NSTEMI
discharge in
NSTEMI vs STEMI
UA

NSTEMI

STEMI

UA

Fox KAA et al. BMJ 2006;333:1091-1094

 Risk Stratification is important in NSTE-ACS
Management

1 CLINICAL CONDITION

2 3
TIMI SCORE GRACE SCORE

Less accurate in predicting events but recommended as the preferred

its simplicity makes it useful and classification to apply on admission
widely accepted and at discharge in daily clinical
routine practice

Hamm W et al. European Heart Journal 2007; 28:15981660; Hamm CW et al. Eur Heart J
2011;32:2999 3054
 HIGH RISK VERY HIGH RISK
Relevant rise or fall in troponin
Dynamic ST- or T-wave changes Haemodynamic instability or
(symptomatic or silent) cardiogenic shock
GRACE Score > 140 Recurrent or ongoing chest pain
refractory to medical treatment
Life-threatening arrhythmias or
cardiac arrest
Intermediete RISK
Diabetes mellitus Mechanical complications of MI
Renal insufficiency Acute heart failure
(eGFR <60 mL/min/1.73 m) Recurrent dynamic ST-T wave
LVEF < 40% or congestive HF changes, particularly with
Early post infarction angina intermittent ST-elevation
Prior PCI
Prior CABG
GRACE risk score 109 - 140

Roffi M et al. European Heart Journal 2015. doi:10.1093/eurheartj/ehv320

 TIMI Risk Score for NonST-Segment Elevation Acute Coronary Syndromes

Past Medical History Clinical Presentation

Age >65 years ST-segment depression (>0.5 mm)
>3 Risk factors for CAD >2 episodes of chest discomfort in the past 24 hrs
Hypercholesterolemia Positive biochemical marker for infarctiona
HTN
TM
Smoking
Family history of premature CHD
50% stenosis of coronary artery)
Use of aspirin within the past 7 days
Using the TIMI Risk Score
One point is assigned for each of the seven medical history and clinical presentation findings. The score (point)
total is calculated, and the patient is assigned a risk for experiencing the composite end point of death, myocardial
infarction or urgent need for revascularization as follows:
High Risk Medium Risk Low Risk
TIMI risk score 57 points TIMI risk score 34 points TIMI risk score 02 points
aTroponin I, troponin T, or creatinine kinase MB greater than the MI detection limit.
60
DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy: A Pathophysiologic Approach, 7th Edition:
http://www.accesspharmacy.com
 GRACE RISK SCORE
Age ( Years ) Point Heart Rate Creatinin (mg/dl)
< 40 0 < 70 0 0,0 0,39 2
40 49 8 70 89 7 0,4 0,79 5
50 59 36 90 109 13 0,8 1,19 8
60 69 55 110 149 23 1,2 1,59 11
70 79 73 150 199 36 1,6 1,99 14
> 80 91 > 200 46 0,2 3,99 23
Systolic BP (mmHg ) Killip class >4 31
< 80 63 Class I 0
80 99 58 Class II 20
Total possible score is 258
100 119 47 Class III 39
120 139 37 Class IV 59
140 159 26 Cardiac arrest at admission 43
160 199 11 Elevated cardiac marker 15
> 200 0 ST segmen deviation 30
 Bleeding risk score CRUSADE SCORE

Very low < 20 ; low (2130) ; moderate (31 40);

high (4150); very high (50)

Hamm CW et al. Eur Heart J 2011;32:2999 3054

VHD
MR
MR
MR
MR
American Society of Hypertension and the International Society of Hypertension 2013