Post on 06-Jul-2018
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CASE BASE DISCUSSION
Nefrizal Wicaksono01.211.6468
Advisor:dr. H. M. Saugi Adu! " S#.$%
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$a&ien& 'den&i&(
• Na)e : Mr. A
• Age : *0 (ears old
• Se+ : Male
• ,o : -ar)er• eligion : Mosle)
• S&a&us : /)u)
• No. M : 012*6
• oo) : ai&ul 'zza! 2 3*5
• n&r( %a&e : ,une 14&! 201*
• +i& %a&e : ,une 17&! 201*
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History Taking
• Main o)#lain& : !ard &o rea&!ing$a&ien&s ca)e &o '9% Sul&an Agung
Hos#i&al i&! #role) !ard &o
rea&!ing. He co)#lained 2 da(s ago.efore !e ca)e &o '9%" !e as go &oano&!er doc&or u& &!e s()#&o) no&ge&&ing e&&er. He also co)#lained
aou& co))on cold" inso)nia"decrease a##e&i&e 2 da(s ago. Hiss()&o)# reall( dis&ur !is dail(
ac&ivi&(.
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Past illness history
• His&or( of Sa)e 'llness 3;5
• Hypertension History (+)
• %M His&or( 3;5• Hear& %issease His&or( 3;5
• His&or( of %rug Allerg( 3;5
• History o s!oking (+)
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"a!ily illness history
• No fa)il( !as &!e sa)e illness
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So#ial E#ono!i# history
•
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Syste!i# ana!nesis
• 9eneral : Weakness• Skin : '&c!( 3;5" Wound 3;5" ,aundice 3;5"
$ale 3;5
• Head : %izziness 3;5
• (es : ed e(e 3;5" ane)ic con?unc&iva 3;5" ?aundice sklera 3;5" ode)e #al#era 3;5
• ars : Hearing loss 3;5" ringing 3;5"
disc!arge 3;5• Nose : #is&a+is 3;5" %isc!arge 3;5
• Mou&! : Sianosis 3;5" S#rue 3;5" leedinggu)s 3;5 NORMAL
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on@&
• Neck : Selling 3;5" neck s&iness 3;5"
• !es& : !es& #ain 3;5" #al#i&a&ion 3;5
• 9'< : Appetite (+)" Nausea 3;5" vo)i& 3;5"
!e)a&e)esis 3;5" ado)inal #ain 3;5• /rogeni&al : d(suri 3;5" !e)a&uri 3;5" &ea
colour of urina&ion 3;5
• Musculoskele&al : #ares&esia 3;5" o ack $ain
3;5
• +&re)i&( : oede) 3;B;5" #ares&esia 3;B;5 a&inferior eks&re)i&as" ound 3;B;5
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PH$SICA% E&A'INATION
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'n&er#re&a&ion :!(#er&ansion
grade 2
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ital Sign
Bloo Press*re ,-./,.. !!Hg
$ulse 3H5 : 100 +B@
: 6 +B@ < : *"8 Cc
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• Head : Mesoce#!al 3;5
• (es : con?unc&iva ane)ic 3;B;5" ?aundicesklera 3;B;5
• Nose : Nos&ril rea&! 3;5" disc!arge 3;5• ars : %isc!arge 3;5"
•
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Thoraks 0 Cor
• 'ns#ec&ion – 'c&us cordis can e seen
•$al#a&ion – I#t*s #oris palpa1le2 thrill (+)2
p*ls*s inter#ostalis (+)" #ulsuse#igas&ric 3;5" #ulsus s&ernal lif& 3;5
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• $ercussion
– /##er orderline : 'S '' linea s&ernalis sinis&ra
– Wais& : 'S ''' linea #aras&ernalis sinis&ra
– oer rig!& orderline : 'S D linea s&ernalis de+&ra – %o3er let 1orerline ICS I , #! lateral ro!
linea !i#la4i#*laris sinistra
• Auscul&a&ion
• Aor&a valve : S1 E S2 s&andard" addi&ional sound 3;5
• $ul)onal valve : S1 E S2 s&andard" addi&ional sound 3;5
•
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Thoraks 0 P*l!oAnterior Posterior
Stati#Inspe#tion
RR : 36x/min, Hyperpigmentation (-),tumor (-), in!ammation (-), "pi#erne$i (-), Hemit%orax &', *Norma!, &iameter A+ LL
RR : 36x/min,Hyperpigmentation (-), tumor(-), in!ammation (-), "pi#erne$i (-), Hemit%orax &', *Norma!, &iameter A+ LL
Dyna!i#
Inspe#tion
%e mo$ement o %emitorax &',
a.#ominot%oraa! .reat%ing (-),mu"0!e retra0tion o .reat%ing (-),retra0tion * (-)
%e mo$ement o %emitorax
&', a.#ominot%oraa!.reat%ing (-), mu"0!e retra0tiono .reat%ing (-), retra0tion *(-)
Palpation +a!pation pain (-), tumor (-), Ar0u"0o"tae ang!e 122, en!argement o
* (-),tem remitu" &'
+a!pation pain (-), tumor (-),
Ar0u" 0o"tae ang!e 122,
en!argement o * (-),tem remitu" &'
Per#*ssion onor ; B;" dullnes FBF onor ; B;" dullnes FBF
A*s#*ltation ronchi (+) , %ee4ing (-) , $e"iu!er(-) &' ron0%i in t%e .a"a! (&')
ronchi (+) , %ee4ing (-) ,$e"iu!er (-) &'
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A1o!en
• 'ns#ec&ion:• S()e&ric" s(ca&ric3;5" s&riae3;5" sGua)a3;5
enlarge)en& of vena 3;5"
!(#er#ig)en&asi 3;5" s#ider nevi 3;5"ca#u& )edussae 3;5
• Auscul&a&ion : – $eris&al&ic 3F5 Nor)al 320 +B )inu&es5
NORMAL
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A1o!enPer#*ssion
s!if&ing dullness 3F5"undula&ion &es&3;5
He#ar : #eka 3F5" liver
s#an de+&ra 10 c)" livers#an sinis&ra 6 c)
ien : &roue s#ace
&()#ani 3F5
Palpation
S*per5sial )ass 3;5" ado)inal #ain3;5 in lu)al de+& e& sin"cos&over&eral knock
#ain 3;5
Deeper Ado)inal #ain 3;5!e#ar is no& #al#ale"
lien is no& #al#ale"kidne( is no& #al#ale.
NORMAL
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E6tre!ity
S*perior IneriorOee! ;B; ;B;
PittingOee!a
;B; ;B;
Cyanoti# ;B; ;B;
Col E6tre!ity ;B; ;B;
Capillary
7e5lle
;B; ;B;
Cl*11ing"inger
;B; ;B;
NORMAL
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%ABO7ATO7$E&A'INATION
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He)a&olog(
%a1oratoryE6a!ination
7es*lts Nor!al al*e
H1 ,829 ,:2; 0 ,
tro!1osit ;?. ,9.088.
leukosi&osis
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lood !e)is&r(
%a1oratoryE6a!ination
7es*lts Nor!al al*e
@DS ,:> ,. = 9.
Creatinin ,28; .2> = ,2,
Troponi I *ltra .2.8 .2.,
• A4otemia
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EC@
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Minggu, 5-6-7258
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9 'n&e#re&a&ion
• !(&) : eguler• -reGuenc( : 100 )Bs
• A+is : Nor)al
•
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7ONT@EN THO7A&
14 , 201*
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14 ,une 201*
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'N
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INTE7P7ETATION
E#ho s*!!ary
• %i)ensi ruang ?an&ung
• %inding D• Wall )o&ion
• Ka&u# ?an&ung
• -ungsi D sis&olik)enurun
• -ungsi D sis&olikaik
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Anor)al %a&a
HistoryTaking
• d(s#neu
Physi#alE6a!ination
•Weakness• ronk!i• enlarge)en&of &!e !ear&
• lood #ressureis !ig!
%a1oratory
an7aiology
E6a!ination
• o
&!e aor&a•$ul)o sus#ec&#ul)onar(ede)a•cocardiogra#!(:
a :!e)a&olog(
•eukosi&osisa : lood!e)is&r(•Azo&e)ia•Hig! level of
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$role) is&
• H(#er&en&ion 9rade ''
• H- NHA 'D
• S&ea)i• Mi&ral regurgi&a&ion
• azo&e)ia
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Hi#er&ension grade ''O Ass enigna !(#er&ansion 3re&ino#a&i 1 E 25
O )aligna !(#er&ension 3re&ino#a&i E45O IpD6 fundusco#(
O IpT6
O Non Phar!a#ology
O o sal& in&ake
O Phar!a#ology
O -urose)id 1 A iv
O a)i#ril 3ardace 51+2"*)g
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O Ip'6 O Di&al Sign"elek&roli&"
O IpE6
O %ie& lo sal&O onsu)#&ion vege&ale" frui&
O ou&ine consu)#&ion drugs
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CH" N$HA I
• Ass : diagnose e&iolog(
DH%
'H%
HH%
%iagnose Ana&o)i
DHAH
-ungsional
NHA 'D
• '#%+ :
HA%'9A-• '#
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• Ip '6 @eneral2 4ital sign2 EC@2e#ho#ariography
• Ip E6
ed es&Bes&ric&ion of #!(sical ac&ivi&(
Sodiu) E -luid Pres&ric&ion
educing )o&ional s&ress alor( res&ric&ion in overeig!& #a&ien&
Si& #osi&ion or se&enga! &idur
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S
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M'
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