aprilia cbd dr saugi
TRANSCRIPT
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Case Based Discussion
Complication Congestive Heart Failure
Lecturer Advisor
dr. HM. Saugi Abduh, SpPD,KKV,F!ASM
Presented byAprilia Nugraheni012116332
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PA!"N !D"N!#
Na$e % &r' (
)e* % &ale
Age % 62th #ears +ld
(eligion % &osle$
,ob % -a$ers
Adress % Cabean ( 0./( 6 De$a &( nu$ber % 01'2'04'5
(oo$ % B' !77ah !!' L
Chec in date % 14 &arch 2016
Chec out date % 30 &arch 2016
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ANA&N")!)Chief complaint " D#spneu and chest pain
Patient came to the slamic hospital Sultan Agung $ith c
complains d#spneu and chest pain since &' month ago. d#s
become aggravate and patient %elt di(cult to breath, d#sp
sleep. Chest pain located on the le%t side. )he patient %elt a
%ullness, s$ollen limbs, abdominal bloating, constipation .
has abdominal %ullnes * month ago.)he patient also comp
$ea+ness and being lethargic, and %ever. Petient is heav#
cigarette since he $as #oung and coee. He has diagnostic
disease &' month ago. His mother have lung disease.
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Past History
DM history (-)
Hypertension (-)
Hyperlipidemia (-)
Heart disease (+): 17 month ago
Smooking cigarette (+)
Overeight (+)
Family History
DM history (-)
Hypertension (-)
Heart disease (-)Overeight (-)
Hyperlipidemia (-)
Personal and social history
!atient is a "amer# hospital cost $y %&'
He has children and all o" them has $een marriage
conomic stat*s : middle-lo
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Review of systems ( Head-to-toe evaluation)
Skin: $ron skin#
Head : headache (+)
ye : blured vision +/+, red eyes --# icteric --
ars: hearing lost --# ring --# discharge --
'ose : $leeding --# discharge --
Mo*th : cyanosis -# thrush -# bleeding gums -
,hroath : pain salloing -, hoarseness +, difficult in swallowing +, snoring-
'eck : enlargment o" the gland - hest : dyspne* +# pain +# co*gh +# $lood-# sp*t*m (+)
ardiac : chest pain +# palpitations +
Stomach : a$dominal pain +# decreassed appetite+# na*sea +# vomiting-#
de"ecation miction -+
M*sc*losceletal : eakness +# rigid -# pain -
.trimity : oedem on *pper and loer e.trimity (+)# /lcers (-)#
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Physical "*a$ination
-eneral status• -eneral " D#spneu, chest pain and oedem
• !utrient Status " H1 &'2cm, 31 45 +g 6M 1 3+g07H 8 m80
1 457*,59':
1 94,'9;2'44 94.4 " over$eight
• *5>above " obese
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Vital Sign
• 6P " &957;5 mmHg
• H? " ;* bpm@ regular ritmic,eualit# same, pulse alternan>0 pulse deBcit >0
amplitude strong.• 6F " 9; times7minute
• )emp "*;.2 degree o% celcius
Head " chepalgia /0#es " anemic conungtive >07>0, icteric >07>0ars " Hearingloss >07>0, discharge >07>0!ose " S#metric, secret>0, nostril breath >0sophagus " h#peremic >0, pain devour>0
Mouth " c#anosis >0, dr# lips /0!ec+ " trachea deviation >0, l#mph h#pertrop# >0Chest" barrel chest /0 ,
E Stomatch " acites /0,S+in " h#perpigmentation achantosis nigricans0/0trimit# " 0, pitting udem /0
!)?P?)A)
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Thorax-pulmonary
inspection Anterior Posterior
)tatic •B8% 30t/$inute•Dia$eter AP9LL•:e$ithora* si7e L;(•:yperpig$entation spidernavi tu$or in?a$ation •)!C% retraction intercosta
•B8% 30t/$inute•Dia$eter AP9LL•:e$ithora* si7e L;(•:yperpig$entation sptu$or in?a$ation •)!C% retraction intercosta
Dyna$ic •:e$ithora* $ove$ent L;(• Additional $ucsle respiration
•:e$ithora* $ove$ent L;• Additional $ucsle respira
Palpation Anterior Posterior
De*tra Palpation pain tu$or ste$-re$itus de*tra;sinistra retractionintercosta
Palpation pain tu$or de*tra;sinistra
)inistra Palpation pain tu$or ste$-re$itus de*tra;sinistra
Palpation pain tu$or de*tra;sinistra
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Auscultation Anterior Posterior
De*tra esicular ronchi hee7ing pleural rub
esicular ronchi hee7ing pleural rub
)inistra esicular ronchi hee7ing pleural rub
esicular ronchi hee7ing pleural rub
Percussion Anterior Posterior
De*tra )hi-ting dullnes )hi-ting dullnes
)inistra )hi-ting dullnes )hi-ting dullnes
interpretation : dyspneu, susp oedem pulmonary
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Thorax-Cardiac
!nspection !ctus cordis seen
Palpation !ctus cordis is palpable on )!C !! linea $id clavicle sinistra t
Percution Dull sound•pper broderline o- heart % )!C !! Linea sternalis sinistr•aist o- heart % )!C !! Linea parasternalis sin•Loer (ight broderline o- heart % )!C ! $id claviculla de*tra•Loer Le-t broderline o- heart % )!C Linea a*illaris ansinistra
Auscultation •Aorta alve % ) ! !! pure reguler ' A1EA2•Pul$onal alve % ) ! !! pure reguler ' P1EP2• riuspidal alve % ) ! !! pure reguler ' 192•&itral alve % ) ! !! pure reguler ' &19&2•Additional sound % interpretation : Susp. Cardiomegali
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Interpretationv Interpretation
Abdomen
!nspection Distention cicatrice striae caput $edusa enlarg$ent o- vein
Auscultation Peristaltic F 1 ti$es / $inute
Percution hy$pani all abdo$inal sur-aceLiver span % de*tra F 13 c$' )inistra F c$'
raubeGs space % )hiting dullness %
Palpation )uperHcial % &ass Deeper % Abdo$inal pain hepato$egali spleeno$egali &urphy signs
Interpretation : susp. Ascites , hepatomegali, spenomegali
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xtrimities Superior n%erior
"de$a @/@ @/@
Cold "*tri$ity =/= =/=
(e?e* physiologist @/@ @/@
!cteric =/= =/=
xtrimities
Interpretation : oedem extrmity, pitting edema
Pitting ede$a /7/ /7/
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8ollo p&4>5*>95&:
95>5*>95&:
9&>5*>95&:
99>5*>95&:
9*>5*>95&:
92>5*>95&:
9=>5*>95&:
9:>5*>95&:
9'>5*95&:
Dyspneu
Dyspneueaness
Le-t leghurt
Le-t leghurt
eanessleg hurt
eaness
eanessde-ecation=
eanessdyspneu
eande-ecan =
120/0 40/0 110/50 120/50 0/0 10/100 130/0 120/0 130/0
3 bp$ = bp$ 100bp$ 63 bp$ 4bp$ 10bp$ 5bp$ 13bp$ 4bp$
30 t/$ = t/$ 22t/$ 2 t/$ 2t/$ 2t/$ 20t/$ 35t/$ 2t/$
36 dc 35 dc 36'5 dc 36'4dc 35'dc 3'dc 34'1dc 34'.dc 35'dc
111 4. 4. 4. 152 10 11 10 116
Date
)
BP
:(
B8
ID)
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LAB+(A+(# "JA&!NA!+ :e$atology and Che$ical&4>5*>95&: ?esult !
APP/PK 236 second 21'=2'0
Control 254 second 20'4=2'3
PP 12 second 4'3=11'
Control 11 second '=12'0
&4>5*>95&: ?esult
Protein otal .3
Albu$in 22
Ilobulin 3'06ID) 111
Conclusion" hipoalbuminemiaeu+ositosis, h#peruricemia,aIotemia
957>5*795&: ?esult !
:e$oglobin 1. 13'5=15'3
:e$atorit 5'6 33=.Leuosit 1'1. 3'=10'6
ro$bosit 3.5 1.0=0
9575*795&: ?esult
ric Acid '
reu$ 62
Creatinin darah 1'.3
Natriu$ 11'4
Kaliu$ '31
Cloride 101'
Calciu$ 4'5
&agnesiu$ 1'4
:BsAg Non reati- N
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K!&!A BL++D IA) ANAL#)!)
957*795&: ?esult !
8!+ 5.'0
p: 5'3. 5'35=5'.
p: 5'3
pC+2 3. 33=
pC+2 36
p+2 .0 51=10
p+2 .3
)02M 4=4
:C .2 34=4
:b 15' 13'2=15'3
:C+3 14'3 22=24
C+2 20' 23=25
A=aD+2 0'6
+2Ct 20'6
Lactate 3'05
Conclusion% asidosis
respiratori
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"KI!N"(P("A!+N
1' (hyt$ % regular sinu
2' :eart rate % 1.00/ 20% 5.3' A*is % lead ! Av-
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C:") J (A#
nterpretation C
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"C:+CA(D!+I(AP:#
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ABN+(&AL!# DAAAnamnesis
1' Dyspneu 2' +rthopneu 3' Chest pain le-t
side' eaness and
being lethargic
.' 8ever 6' )$oing
cigarette5' !ncreasing hrist
' Cough
Ph#sical amination
&. Achantosis !igricans &09. blured vision /7/ 90*. )tv HLP
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P(+BL"& L!)1' Congestive :eart 8ailure
2' +vereight
3' "-usi Pleura
' )yo cardiogenic
.' :ipoalbu$ine$ia6' A7ote$ia
5' (+&B)
' :iperurise$ia
!P
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C+NI")!" :"A( 8A!L("
Assesse$ent Diagnosis etiology%
hypertension cardio$yopathy $iocarditis
Diagnosis anato$y%
L:(: Diagnosis -unctional%
N#:A grade 3 O
!P D* P(+ N P(+ BNP
!P * 8ar$acology
8urose$id 20$g 1*1
P+% Bisoprolol )pironolaton
A(B
As' -olat
Non 8ar$acology +2 canule 2= liter/ $enit
)aturasi +2 E40 M
!P &* -eneral Condition
Vital Sign
Che$ical O he$atologi s
!P "*:eart&aint
eigPhys)top
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+"("!I:
Assesse$ent
!P D*
!P * :itung alori Ieneral advice on health
eight and li-e style Consider surgery
!P &* &onitoring eight every
ee
aist circu$-erence !P "*
Diet Lo Calory Diet Lo 8at
!P *
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"8)! PL"(A
Assesse$ent ransudat
esudat
!P D* (ivalta test
!P * )esuai dengan etiologi
ransudat atau esudat
8ar$acology Antibiotics% ce-tria*on 1*1 Bro$he*in hydroclorid $g/2$l
(anitidin .0$g 2*1 A
Non 8ar$acology
pungsi
!P &* Bloodtest
BIA
!P "J Adeuate restat night
aing naps during the day i- needed
(ehidration
8inishing all o- their antibiotic$edications
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)#+K KA(D!+I"N!K
Assesse$ent
&engatasi egaatan
!P D* "CI
!P *
Loading cairan• dobuta$in .$cg/gb
• "pineprin 3A
Non -ar$aology%
+2 possitive pressure 6=
!P &*• ital sign
• "CI
!P "*
Q
!P *
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AR+"&!A
Assesse$ent Chronic idney
disease
Acute renal -ailure
!P D*
)I Abdo$en
8ar$acologic
Non 8ar$acologic Lo protein intae 0'6=0' g/g/day
!P &* rine product Bioi$ia blood e*a$ination rine e*a$ination I8(
10=age *BB /52 *creatinine seru$ *40/52*1'.3 ; 635 L8I nor$al % S40 L8I T $ild % 60=4 L8I T $oderate% 30=.4 L8I T servere % 1.=24 CKD %E1.
Che$ical blood e*
!P "*
Diet lo salt Diet Lo protein
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:#P+ALB&!N"&!A
Assesse$ent
IgIA pre renal )indro$a Ne-roti )irosis hepati
!P D*
Pitting ede$a
!P * 8ar$acology
Albu$in 20M
3.22 *40*0; 5
Non 8ar$acology Diet tinggi protein
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(+&B)
Assesse$ent
&encegah egaatan
!P D*
!P * :eparin 1.0'000/2Ua$< u
heparin> resio perdarahan "no*aparin' AriJtra < lo $
heparin> resio perdarahan ial .000iu/$l * .$l
Non -ar$aology%
Diet lo$ %at D0 " vegetable, pe !P &*
• ital sign
• PAP !P "*
Bed rest
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:!P"((!)"&!A
Assess$ent% =
!P D*
!P *
Allopurinol 100$g 30
Non -ar$aology% Diet lo$ purin
!P &*
• Bioche$ia blood e*post oresi asa$ u
!P "*
Diit lo purin B"N,+
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