CASE BASED

DISCUSSION
Department of Internal Medicine
Sultan Agung Islamic University

Nisrina Imtiyaza
30101407270
 PATIENT’S IDENTITY
• Name : Mr. S
• Patient ID : 01-17-29-XX
• Age : 60 years old
• Sex : Male
• Religion : Islam
• Address : Karangasem RT 02 RW 01 Sayung, Demak
• Occupation : Swasta
• Room : Na’im
• Date of Examination : 22 June 2020
• Class : BPJS
 HISTORY TAKING

Chief Complain History of present illness

● Patient came to ER of Sultan Agung
Dsypneu Islamic Hospital, complaining
dyspnea from 2 weeks ago, he also
said that he can’t sleep every night
because of the dyspnea, he felt
better when change the position
into erect position. He has history of
Cardiac disease before, about 1
 HISTORY OF ILLNESS

HISTORY OF FAMILY HISTORY OF SOCIO-

PREVIOUS DISEASE (GENETIC- ECONOMIC
ILLNESS RELATED) PROFILE
• History of Same Illness (+) •Hypertension history (+)
BPJS NON PBI
• Hypertension’s history (+) •DM history (-)
• Prostate history (+) •Heart Disease History (-)
• Gastritis (+)
• Post PCI
• The history of DM (-)
• Smoking (-)
• Alcohol (-)
SISTEMIC ANAMNESIS

Chief Complaint : Dyspneu

Onset : 2 week ago
Location : Chest
Chronology : 2 week ago about his dyspnea. He felt hard to breath when
he was in home while doing some home activity. He also feels pain on his chest.
Because of that, the patient was taken to RSISA and got treated in Naim .
Quality and Quantity : Patients feel dyspnea without activity.
Modification factor : Better when he is in steady position.
Comorbid complains : Gastritis
 01
PHYSICAL
EXAMINATION
VITAL SIGN
o General condition : Composmentis
o Awareness : E4M6V5 (GCS : 15)
o Vital Sign
 Blood Pressure : 184/87 mmHg
 Pulse : 91x/menit , regular, normal pulse
 Breath Frequency : 24 x/minute
 Temperature : 36,5oC
 SpO2 : 100%

Intepretation : hypertension
Intepretation : hypertension
NUTRITION STATUS
● Body mass index:

○ Weight : 69 kg

○ Height : 170 cm

○ BMI : 23,8 kg/m2

Interpretation : Normoweight
Interpretation : Normoweight
GENERAL
EXAMINATION
• Head : Mesocephal, alopesia (-)
• Eyes : Anemic Conjungtiva(-/-), Icteric sclera(-/-)
• Nose : secret (-), Nostril Breath (-)
• Ears : Normal Shape, discharge (-/-)
• Esophagus : Hyperemic (-), pain devour (-)
• Mouth : Cyanosis (-)
• Neck : Trakhea deviation (-), Lymph Hypertropy (-), Increasing JVP(-)

Interpretation : normal
EXAMINATION ANTERIOR POSTERIOR
Inspection – Static CHEST EXAMINATION - LUNG
RR : 20x/min RR : 20x/min
Thoracal breathing Thoracal breathing
Hyperpigmentation (-) Hyperpigmentation (-)
Spider nevi (-) Spider nevi (-)
Atrophy M. Pectoralis (-) Atrophy M. Pectoralis (-)
Hemithorax D=S Hemithorax D=S
ICS Normal ICS Normal
Diameter AP < LL Diameter AP < LL

Inspection – Dynamic Up and down of hemithorax D=S Up and down of hemithorax D=S
Muscle retraction of breathing (-) Muscle retraction of breathing (-)
Retraction ICS (-) Retraction ICS (-)

Palpation Tenderness (-), Mass (-) Tenderness (-), Mass (-)

tactile fremitus (N) tactile fremitus (N)

Percussion Sonor (+) Sonor (+)

Auscultation Ronchi (-), Wheezing (-), Ronchi (-) Ronchi (-),, wheezing (-), Ronchi (-)
 THORAX - COR

INSPECTION Ictus cordis seen.

PALPATION Ictus cordis is palpable at ICS VI linea axilaris anterior sinistra 1 cm to media, thrill
(-), epigastric pulse (-), parasternal pulse (-), sternal lift (-).

PERCUSSION • Upper borderline of heart: ICS II left sternal line

• Waist of heart : ICS III left parasternal line
• Lower right borderline of heart : SIC V linea sternalis dextra
• Lower left borderline of heart : SIC VI Linea Axillaris Anterior Sinistra

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 (-)

Interpretation =
Kardiomegali
ABD
EXAMINATION RESULTS
OME Inspection Symmetrical, cicatrix (-), Striae (-), Vein’s enlargement (-), Caput
medusa (-), Spider nevi (-)

N the right inguinal area is a bump, edema (-), reddish skin color

Auscultation Peristaltic (+), Abdominal aorta’s bruits (-), Splenic Artery, Femoral
Artery (-)
Percussion Tympanic, Shifting dullness (-) Undulation test (-), Liver dullness (-),
Liver span (-), Traube’s space (tympanic)

Palpation Mass (-), Pain (-), Hepatomegaly (-), Liver, Kidney & Spleen are
normal, Splenomegaly (-)
Murphy’s sign (-)

Interpretation =
Normal
 EXTREMITY EXAMINATION
Superior Inferior

Oedem -/- -/-

Pitting Oedema -/- -/-

Cyanotic -/- -/-

Cold Extremity -/- -/-

Capillary Refille 2s 2s

Clubbing Finger -/- -/-

Ulcer -/- -/-

Intepretation: normal
Intepretation : normal
 02
ADDITIONAL
EXAMINATION
 ECG
(ELECTROCARDIOGRAPHY
EXAMINATION)
THE EXAMINATION
USING ECG
 INTERPRETATION
● Rhytm : Sinus
● Regularity : Regular
● Frequency : 75 x/m
● Axis : lead 1 (+), AvF (+) (NAD)
● Transition zone : V3
● Q patologis :-
● P wave : 0.08s
● PR Interval : 0,16 s (normal) Intepretation : sinus rythm with acute
● QRS complex : 0,08 s (normal) Intepretation : sinusinfark
myocard rythm with acute
inferior
myocard infark inferior
● T wave : normal
● ST segment : ST elevasi di Lead III,avF,
Laboratory
Examination
HEMATOLOGY EXAMINATION (BLOOD ROUTINE TEST)

EXAMINATION TEST RESULT NORMAL VALUE

Hemoglobin 12.5 11.7-15.5

Hematocrite 38.7 33-45

Leukocyte 6.54 3.6-11.0

Erithrocyte 4.5 4.4-5.9

Thrombocyte 179 150-440

Intepretation : normal
Intepretation : normal
HEMATOLOGY EXAMINATION (DIFF COUNT)
EXAMINATION TEST RESULT NORMAL VALUE

Eosinofil % 8.9 (H) 1-3

Basofil % 1.2 (H) 0-1

Neutrofil % 57.5 50-70

Limfosit % 22.3 (L) 25-40

Monosit % 10.1(H) 2-8

IG % 0.3

Intepretation :
Intepretation
eosinophilia :
(high eosinophil),
eosinophilia
basophilia (high eosinophil),
(high basophil), limfopenia (low limfosit)
basophilia (high basophil), limfopenia (low limfosit)
HEMATOLOGY EXAMINATION (ERITHROCYTE INDEX)

EXAMINATION TEST RESULT NORMAL VALUE

MCV 90.1 80-100

MCH 28.2 26-34

MCHC 32.3 32-36

Intepretation : NORMAL
Intepretation : NORMAL
 BLOOD CHEMICAL TEST
EXAMINATION TEST RESULT NORMAL VALUE

Blood glucose 88 75-100

Ureum 42 10 - 50
Blood Creatinin 1.06 0.7 – 1.3

CKMB 20 <24

High Sensitive Troponin I 13 <19 ng/L

Na 141.0 135-147

K 4.52 3.5-5

Cl 103.5 95-105

Intepretation : normal
Intepretation : normal
RADIOLOGIC
EXAMINATION
X-FOTO THORAX

DESCRIPTION :
● COR
Apex to the laterocaudal
Elongation of Arcus Aorta
● LUNG
 Bronchovascular pattern not increase
 Infiltrat (-)
● CONCLUSION
 Cardiomegaly (LV)
 Elongatio Aorta
ECHOCARDIOGRAPHY
 Echo Summary
Heart Room Dimension : no enlarge
LV Wall : no enlarge
Wall motion : Global normokinetik
Heart Valve : Normal
Systolic LV Function is Good EF 64%
Systolic RV Function is Good TAPSE 22 mm
Dyastolic LV Function is Good E/A <1

INTERPRETATION :
Global Normokinetic
Systolic Function LV and RV is Good
Dyastolic LV Dysfunction
CATHETERIZATION
• Stenosis 80% di RCA
• Stenosis 70-80% di LAD
• Stenosis 70% di LCX

Kesan :
• CAD 3 VD
 03
ABNORMAL DATA
Abnormal Data
ECG :
History Taking sinus rythm with acute myocard infark
 Chest Pain Lab inferior
 Hypertension History (+) • Eosinophilia
 Prostate History • Basophilia Echocardiography :
 Gastritis History • Limfopenia • Global Normokinetic
 Post PCI • Systolic Function LV and RV is Good
• Dyastolic LV Dysfunction

X-Ray :
 Cardiomegaly
 Elongatio Aorta
Physical Examination
 High blood pressure : 184/97 Catheterization
 Cardiomegaly  CAD 3 VD
 04
PROBLEM LISTS
 Problem List

Congestive Acute coronary Hypertension

Heart Failure Gastritis
syndrome stage III
1. Dypsneu
2. Orthopnea
3. Paroxysmal
Nocturnal Dyspnea
4. Tachypneu
5. Cardiomegaly
 1. CONGESTIVE HEART FAILURE

– Ass : Ip Tx :
• Furosemide 3x1 amp IV (20mg/2mL) give when the sistolyc
– Anatomi : disfunction LV blood pressure more than 100 mmHg
• Captopril 6.25 mg 3x1
diastolik • Bisoprolol 5 mg 1x1
• Spironolactone 25 mg 1x1
– Fungsional : NYHA IV Non farmacology
- Low fat intake
– Etiology : IHD, VHD - Reduce activity
- Low salt intake
IP Dx :
- BNP (≥ 35 pg/mL) dan NT Pro-BNP (≥ IP Mx. = vital sign, awareness
125 pg/mL) IP Ex. =
 Bed Rest/Restriction of physical activity
 Reducing Emotional stress
 Routine consumption drugs
 Sit position or a half sleep position
 Restriction fluid (max 1L/day)
 2. ACUTE CORONARY  Pharmacology
SYNDROME Nitrokaf 2.5 mg 1x1
– Ass:
Aspirin 80 mg 1x1
STEAMI
Bisoprolol 2.5-5 mg 1x1
Unstabel Angina
Fondaparinux 2.5 mg 1x1 ( for 5 – 8 days )
Non ST Elevasi Myocard Infarction (NSTEAMI)

–
Atorvastatin 20 mg 1x1
IP Dx : Troponin I, Troponin T, Profil Lipid ,
Invasive angiography Clopidogrel 75 mg 1x1
– IP Tx : Ip.Mx : ECG serial, Vital Sign
 Non Pharmacology
Ip.Ex :
 Low Fat Intake
 Reducing Emotional stress
 High Fiber diet

 Reducing eat that food contain high cholesterol

 3. PROSTATE

ASS : Non pharmacology

Urinary tract infection • Limit beverages in the evening. Don't drink anything for an
Cancer of the prostate or bladder hour or two before bedtime to avoid middle-of-the-night trips
to the toilet.
IP Dx : • Limit caffeine and alcohol. They can increase urine
Culture urin , PSA , urine test, blood test production, irritate the bladder and worsen symptoms.
• Limit decongestants or antihistamines. These drugs
IP Tx : tighten the band of muscles around the urethra that control
Pharmacology urine flow, making it harder to urinate.
- Avodart 1x1 • Go when you first feel the urge. Waiting too long might
- Tamsulosin 2x1 overstretch the bladder muscle and cause damage.
- Ciprofloxacine 2x1 • Schedule bathroom visits. Try to urinate at regular times —
such as every four to six hours during the day — to "retrain"
the bladder. This can be especially useful if you have severe
frequency and urgency.
 3. PROSTATE

IP.Mx : PSA (PROSTATE SPECIFIC ANTIGENT)

IP.Ex :
Limiting heavy lifting and excessive exercise for seven days if you have laser
ablation, transurethral needle ablation or transurethral microwave therapy. If you
have open or robot-assisted prostatectomy, you might need to restrict activity for
six weeks.
 4. GASTRITIS
ASS :
• Organic dispepsia (duodenal ulcer, gastric ulcer, gastritis)
• Functional dispepsia (Post prandial distress syndrome, epigastric pain syndrome)

IP Dx :
• Kontras OMD, endoskopi, urea breath test, PPI Test

IP Tx :
Pharmacology
• Omeprazole 20 mg 2x1
• Ondansetron 3x4mg
• Sukralfat syr 3x1 C

Non pharmacology
• Reduce fiber food, spicy and acid food
• Avoid alcohol, soda
• Reduce emotional stress
 4. GASTRITIS

IP.Mx :

• Dehidration state, general examination (ikterik, odinofagia, vomitus,

• nausea, limfadenopathy, hematemesis/melena without etiology)
• Hb

IP.Ex :

• Reduce eat spicy, acid and fatty food

• Avoid alcohol, soda
• Reduce emotional stress
• Increase diet frequent with small portion
PROSTATE
– Your doctor will start by asking detailed questions about your symptoms and doing a physical exam. This initial exam is likely to
include:
• Digital rectal exam. The doctor inserts a finger into the rectum to check your prostate for enlargement.
• Urine test. Analyzing a sample of your urine can help rule out an infection or other conditions that can cause similar symptoms.
• Blood test. The results can indicate kidney problems.
• Prostate-specific antigen (PSA) blood test. PSA is a substance produced in your prostate. PSA levels increase when you
have an enlarged prostate. However, elevated PSA levels can also be due to recent procedures, infection, surgery or prostate
cancer.
– After that, your doctor might recommend additional tests to help confirm an enlarged prostate and to rule out other conditions.
These tests include:
• Urinary flow test. You urinate into a receptacle attached to a machine that measures the strength and amount of your urine flow.
Test results help determine over time if your condition is getting better or worse.
• Postvoid residual volume test. This test measures whether you can empty your bladder completely. The test can be done
using ultrasound or by inserting a catheter into your bladder after you urinate to measure how much urine is left in your bladder.
• 24-hour voiding diary. Recording the frequency and amount of urine might be especially helpful if more than
one-third of your daily urinary output occurs at night.
– If your condition is more complex, your doctor may recommend:
• Transrectal ultrasound. An ultrasound probe is inserted into your rectum to measure and evaluate your
prostate.
• Prostate biopsy. Transrectal ultrasound guides needles used to take tissue samples (biopsies) of the prostate.
Examining the tissue can help your doctor diagnose or rule out prostate cancer.
• Urodynamic and pressure flow studies. A catheter is threaded through your urethra into your bladder. Water
— or, less commonly, air — is slowly injected into your bladder. Your doctor can then measure bladder pressure
and determine how well your bladder muscles are working. These studies are usually used only in men with
suspected neurological problems and in men who have had a previous prostate procedure and still have
symptoms.
• Cystoscopy. A lighted, flexible instrument (cystoscope) is inserted into your urethra, allowing your doctor to see
inside your urethra and bladder. You will be given a local anesthetic before this test
HYPERTENSION HEART
DISEASE
Source : ESC 2018
ISCHEMIC HEART
DISEASE
Thrombus Formation and ACS
Plaque Disruption/Fissure/Erosion

Thrombus Formation

Old
Terminology: UA NQMI STE-MI

New Non-ST-Segment Elevation Acute ST-Segment

Terminology: Coronary Syndrome (ACS) Elevation
Acute
Coronary
Syndrome
(ACS)
 79 Chest pain
ACS
ST elevation ST depression
ECG ST segment

Bio-chemistry Troponin rise / Troponin

fall normal

Diagnosis

STEMI NSTEMI UA

Adapted from Hamm CW et al. Eur Heart J 2011;32:2999 – 3054, Davies MJ. Heart 2000;83:361–366
96
DISPEPSIA
Alarm symptom for dispepsia

1. Decreasing of weight gain > 10% without any reason

2. Progressive disfagia
3. Vomitus frequent
4. Gastrointestinal bleeding
5. Anemia
6. Fever
7. Epigastrium mass
8. Family history of ca gaster
9. Acute dispepsia on age 45
JAZAKUMULLAH.
TERIMAKASIH