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CASE BASED DISSCUSIONGITHA AYU ASTARIKA(01.208.5662)

ADVISORdr.LUSITO, Sp.PDPATIENT IDENTITYHISTORY TAKINGSystemic Anamnesis PHYSICAL EXAMINATIONTHORAX - PULMONARYINSPEKSIANTERIORPOSTERIORStaticRR : 30 x/min, Hiperpigmentation (-), spider nevi (-), atrofi M. Pectoralis (-), Hemithoraks S=D, ICS extend (-), Diameter AP < LLRR : 30 x/min, Hiperpigmentation (-), spider nevi (-), Hemithoraks Hemithoraks S=D, ICS extend (-), Diameter AP < LLDinamicUp and down of hemitoraks S=D, muscle retraction of breathing (-), retraction ICS (-)Up and down of hemitoraks S=D, muscle retraction of breathing (-), retraction ICS (-)PalpationPalpation pain (-), tumor (-), enlargement of ICS (-), Stem fremitus D=SPalpation pain (-), tumor (-), enlargement of ICS (-), Stem fremitus D=SPercutionSinistra sonorSinistra sonorAuskultationVesicular(+), ronchi (+), wheezing (-)Vesicular(+), ronchi (+), wheezing (-)THORAX - CORInspection : Ictus cordis seen.Palpation: Ictus cordis is palpable in ICS VI linea mid clavicula sinistra, thrill (+).Percussion : hiposonor (dull) soundUpper borderline of heart: ICS II linea sternalis sinistraWaist of heart: ICS II linea parasternalis sinistra Lower right borderline of heart : ICS VI linea parasternalis dextraLower left borderline of heart : ICS VI 2 cm lateral linea mid clavicula sinistraAuscultation : Aorta Valve : SD I-II pure, regular, AIT2Pulmonal Valve: SD I-II pure, regular, P1M2Addition Sound: (S3 Gallop)

Interpretation : cardiomegali

ABDOMENInspection : convex of surface(+), cycatric(-), striae(-), caput medusa (-).Auscultation: peristaltic (+) NPercution: dull (+), shifting dullness (-)PalpationSuperficial: massa (-)Deeper : abdominal pain (-), hepar, lien isnt palpable, renal isnt palpable

Interpretation: Normal Extremities Extremitiessuperior inferior- edema -/- -/-- cold-/- -/-- reflect physiologist+/+ +/+- Icteric-/- -/-

LaboratoryFindingsLABORATORYHiperglikemia26-02-2013HematologiHemoglobin 13,0 g/dlHematokrit39,3%Leukosit6,77 3/uL Eritrosit4,88 6/uL Trombosit 309 3/uLEosinofil %16,1 %HBasofil %0,4 %Neutrofil %37,6 % LLimfosit %40,3 %HMonosit %5,6 %MCV80,5 flMCH26,6 pgMCHC33,1 g/dlLED 114LED 231GDS

131 mg/dlH

Ureum39 mg/dlCreatinin Darah0,97mg/dl

EKG

InterpretasionRhytm : IRegulerHR : 10 x 11 = 110 x/menitAxis :L1(+) & Avf(-) = Left axis deviationTransitional zone :---

Morphology :P wave = 0,08 (2 kk)Interval PR= 0,16 (4 kk) ( Normal (0,16 - 0,20 second))QRS complex: Normal (0,06 0,12 second) Q Wave =Di V4 = kedalamannya = 2kk = Q patologis (infark miokard)Gel. R =- R > 27 kk: V5 : 43, V6 : 25- RV5 + SV1 35: 43+20= 63 35Gel. S = V (+) di V1-V2 = Hipertrofi Ventrikel Kiri ST segment = elevation (+) di V1- V4 = infark anteroseptalT wave = inverted (+) di V5 & V6 = hipertrofi ventrikel kiri,U inverted : (-)

RADIOLOGYCardiomegali

KesanHasil pemeriksaan Foto Rontgen Thorax1. Cor : CTR > 50%, Apeks bergeser ke laterocaudal2. Elongasio Aorta3. Pulmo: corakan bronkovaskular meningkat. Tampak bercak pada kedua paru 4. Diafragma dan sinus kostofrenikus kanan dan kiri normal. Kesan Cor: Cardiomegali (Left ventrikel) Elongasio Aorta Pulmo : Gambaran Bronkopneumonia

Abnormalitas DataPROBLEM LIST1. CHF NYHA III2.HIPERTENSI Grade I3.BRONKOPNEUMONICHF NYHA IIIAssessment: Anatomi diagnosis (LVH,LAH) Etiologi diagnosis (HHD,IHD), Cardiomiopaty, LV Fraksi ejection DislipidemiaIP. Dx : Echocardiography Profil Lipid LVEFIP. Rx :Non Farmacology :Bed Rest of sit down positionKonsumsi air < 1,5-2 l/hari (khususnya pada pasien hiponatremia)Diet TKRPRG ( Tinggi Kalori Rendah Protein Rendah Garam)FarmacologyO2 2-3 L/minutesDigoxin (2x1/2tab) Spironolakton 1x 25 mgInj Furosemid 3 x 1 ampISDN 3x 5 mgIP. Mx : Vital Sign, Fluid Balanced, Electrolit lab, ElectrocardiographyIP. Ex : Kurangi konsumsi garam dan rendah proteinMakan dan minum harus dari RS sesuai programPakai canul O2 untuk mengurangi sesaknyaKurangi konsumsi alcohol, rokok,kopiOlahraga ringan 30 minutes setiap hari Konsumsi obat dengan rutin

Hipertension Grade IAssessmentFaktor Risiko: HiperlipidemiaKerusakan Organ Target: Defisit neurologis,Retinopati, NefropatiIP. Dx :Cek Kolesterol total serum, LDL,HDL serum,Trigliserid serum, CT Scan,Funduscopy, Proteinuria,Kreatinin serum, Laju Filtrasi Glomerulus.IP. Rx :Non FarmacologyDiet Low salt (Dietary sodium restriction to 2-3 g/day is recommended)Avoid stressFarmacologyCaptopril (2x12,5mg)IP. Mx : Vital SignIP. Ex : Kurangi konsumsi garam dan rendah proteinMakan dan minum harus dari RS sesuai programPakai canul O2 untuk mengurangi sesaknyaKurangi konsumsi alcohol, rokok,kopiOlahraga ringan 30 minutes setiap hari Konsumsi obat dengan rutin

BronchopneumoniaAss : Acquired Community Bronkopneumonia Etiologi : specific and non specificIpDx : Bacterial Culture (Sputum), Pengecatan GramIpRx : Non Farmakologic- Avoid Pollutan- Maintain Hygiene Farmakologic- Antibiotic : Inj Ceftriaxon 2x 1gr- Bronchodilator : Salbutamol 2x1- Expectorant: OBH syrup 3xI CIpMx : General condition, Vital signIpEx : Avoid Pollutan Maintain HygieneConsumption drug regulary

FOLLOW UP

Follow UpDateBPHRRRTS O AP26.2.201314090115x30x36,5 oCDyspneu, left chest pain, cough, fatigue, headache and tight in the neckHypertension Grade 1, CHF NHYA III , BRPN,HyperglikemiaECG,RO Thorax, salt ,Bed Rest,1/2 position, Avoid Pollutan, Maintain Hygiene, Diet low glucose

27.2.201314080

100x28x36 oCdyspneu, left chest pain,cough Hypertension Grade 1, CHF NHYA III , BRPNECG,RO Thorax, salt ,Bed Rest,1/2 position, Avoid Pollutan, Maintain Hygiene.28.2.20131308076x26x36,2 oCcoughBRPNAvoid Pollutan, Maintain Hygiene.01.3.20131307080x27x36,5 oCdyspneu,, cough, CHF NHYA III , BRPNBed Rest,1/2 position, Avoid Pollutan, Maintain Hygiene.BB: 64 kgTB: 170 cmAktivitas : istirahat

BBI = (TB-100) x 1kg= (170 -100) x 1kg= 70 kgStatus Gizi = (BB : BBI) x 100% = (64 : 70 ) x 100% = 91,4% Calori Basal = BBI x 30 Calori/kg = 70 x 30 Calori /kg = 2100 Calori/kgKoreksiUmur 40 59 year (-5%)= - 105Aktivitas istirahat (+10%)= + 210Total= 2205kalori HITUNG KALORICBD HOMEWORKPOMR?Dasar Diagnosis CHF?Definisi CHF? ESC Guidline CHF 2007?PND? Ortopnue? DOE?Gejala CHF?Tanda CHF?What is Problem?A PROBLEM is anything that has required, does require, or may require health care management.AssessmentAssessment is the process of making such an evaluation.(in a problem-oriented medical record) an examiner's evaluation of the disease or condition based on the patient's subjective report of the symptoms and course of the illness or condition and the examiner's objective findings, including data obtained through laboratory tests, physical examination, medical history, and information reported by family members and other health care team members.POMRa method of recording data about the health status of a patient in a problem-solving system.POMR = part of an attempt to address the most common problems in diagnosis & case management:Patient focusedProblem oriented Dr. lawrence L. Weed (1950 -1960). Problem Oriented Medical RecordBASIS DATA Anamnesis Umum Khusus Pemeriksaan Fisik Pemeriksaan Lab Rutin DAFTAR MASALAH RENCANA PENGELOLAAN (PEMECAHAN MASALAH) Rencana pemeriksaan penunjang Rencana tindakan dan pengobatan Rencana rehabilitasi Rencana edukasi PELAKSANAAN Tindakan MedisAsuhan KeparawatanFOLLOW UP CATATAN KEMAJUAN SOAP MASALAH BARU Rencana LanjutanPenyebab MasalahDasar Diagnosis CHF?

Penegakkan diagnosis gagal jantung dalam praktek dokter umum adalah dengan kriteria Framingham, dimana keberadaan dua kriteria mayor atau 1 kriteria mayor disertai dua kriteria minor dibutuhkan. Adapun kriteria mayor dan minor pada kriteria Framingham sebagai berikut.Kriteria majorKriteria minorParoxysmal nocturnal dyspnea Peningkatan tekanan vena jugularRonkiKardiomegali pada pemeriksaan radiologi toraksEdema pulmoner akutGallop S3Peningkatan tekanan vena pusat (>16 cmH2O pada atrium kanan)Hepatojugular refluxPenurunan berat badan >4.5 kg dalam 5 hari sebagai respon terhadap terapiEdema pergelangan kaki bilateralBatuk nokturnalDyspnea on ordinary exertionHepatomegaliEfusi pleuralPenurunan kapasitas vital hingga sepertiga dari maksimum (yang pernah tercatat)Takikardia (detak jantung >120 kali/menit)

What is NYHA Classification?Physicians often assess the stage of heart failure according to the New York Heart Association (NYHA) functional classification system. This system relates symptoms to everyday activities and the patient's quality of life.

New York Heart Association (NYHA) classification is used to grade the severity of functional limitations in a patient with heart failureNYHA ClassificationClassPatient SymptomsClass I (Mild)No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath).Class II (Mild)Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.Class III (Moderate)Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.Class IV (Severe)Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.Definisi CHF menurut ESC Guidline CHF 2012Heart failure can be defined as an abnormality of cardiac structure or function leading to failure of the heart to deliveroxygen at a rate commensurate with the requirements of themetabolizing tissues, despite normal filling pressures (or onlyat the expense of increased filling pressures).1 For the purposesof these guidelines, HF is defined, clinically, as a syndromein which patients have typical symptoms (e.g.breathlessness, ankle swelling, and fatigue) and signs (e.g. elevatedjugular venous pressure, pulmonary crackles, and displacedapex beat) resulting from an abnormality of cardiacstructure or function. PND (Paroxismal Nocturnal Dyspneu) Gejala sesak waktu tidur malam lalu terbangun setelah bangun dan harus duduk selama beberapa waktu sampai sesak berkurang. Terjadi karena ketika tidur ( 2- 4 jam) cairan yang berada di extravaskuler masuk ke intravaskuler menimbulkan beban sirkulasi meningkat Edema paru timbul sesak nafas. OrtophnoeSesak saat berbaring berkurang saat duduk atau d ganjal bantal yang tinggi Karena ada kelemahan ventrikel kiri sehingga meningkatkan tekanan vena pulmonalis dan paru sehingga menyebabkan sesak saat berbaring. Jika berbaring aliran vena lebih lancar,pengisian atrium dan ventrikel kanan lebih banyak sehingga aliran darah ke paru-paru meningkat dan menimbulkan bendungan sehingga terjadilah edema pulmo.Dispneu de effortSesak saat aktivitas, menghilang saat istirahat.

Gejala & Tanda CHF menurut ESC Guidline 2008 Tampilan KlinisGejalaTandaEdema Perifer / kongestiSesak nafas, kelelahan, mudah penat, anoreksiaEdema perifer, peningkatan JVP, edema paru, hepatomegali, asites, bendungan cairan, kakeksiaEdema ParuSesak nafas yang sangat berat saat istirahatRonki basah halus atau basah kasar di paru, efusi paru, takikardia, takipneaSyok kardiogenikPenurunan kesadaran, lemah, akral perifer dinginPerfusi perifer yang buruk, tekanan darah sistolik < 90 mmHg, anuria atau oliguriaTekanan darah yang sangat tinggi ( gagal jantung hipertensi )Sesak nafasPeningkatan tekanan darah, penebalan dinding ventrikel kiri, ejeksi fraksi masih baikGagal Jantung kananSesak nafas, mudah lelahTanda-tanda disfungsi ventrikel kanan, peningkatan JVP, edema perifer, hepatomegali, asitesGejala & Tanda CHF menurut ESC Guidline 2012

Terima KasihWassalaamu'alaykum Wr. Wb.

HyperglicemiaAssessment :DM type I, DM type II, Another DMIP. Dx : GDS, GDP, GD2PP. TTGO IP. RXNon FarmacologyDiet low glucoseIncrease Physical exerciseEducating about Diabetes MellitusFarmacology : OHO, Insulin InjectionIP. Mx : General Condition, GDS, GDP, GD2PPIP. EX :Needed controlling and examination for DMDiminished intake high carbohydrate and fattyDo the mild exercise and moderate regulary