CBD Dr.saugi. Sp.pd Nefrizal Edit

8/17/2019 CBD Dr.saugi. Sp.pd Nefrizal Edit

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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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CBD Dr.saugi. Sp.pd Nefrizal Edit

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