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CASE PRESENTATION FATIGUE

GROUP A M Hafiizh – Bonita Effendi – Adly Nanda – Dini Irawan – Anita Santoso - Zanetha – Genesius Nene. CASE PRESENTATION FATIGUE. Supervisor : Dr . Ginova Nainggolan , SpPD -KGH Dr . Zunilda , SpFK. Anamnesis and physical examination were conducted on January 24 th , 2011.

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CASE PRESENTATION FATIGUE

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  1. GROUP A M Hafiizh – Bonita Effendi – Adly Nanda – DiniIrawan – Anita Santoso - Zanetha – Genesius Nene CASE PRESENTATIONFATIGUE Supervisor : Dr. GinovaNainggolan, SpPD-KGH Dr. Zunilda, SpFK

  2. Anamnesis and physical examination were conducted on January 24th, 2011 CASE ILLUSTRATION

  3. Name : Mr. E Age : 53 years old Address : Pondok Bandung, Kota Bambu Utara No. Medical Record: 348-15-14 Date of Admission : January 23rd, 2011 Identity of the Patient

  4. Patient complained of having shortness of breath since 2 days before hospital admission. Chief complaint

  5. Present history of illness 4 years BHA : Diagnosed of having hypertension (systolic pressure 190 mmHg); headache (-), reduced consciousness (-), ches pain (-), slurred speech (-)  uncontrolled Easily getting thirsty, hungry, freq urinating at night, unexplained loss of bodyweight (-) 3 years BHA : Easily fatigue, having shortness of breath at daily activity & sleeps, fatigue & dyspnea cease during rest. Need 2-3 pillows to sleep. Dyspnea at night(+) Dyspnea not related to weather changes, no complain of having “mengik”, edema (-), chest pain (-), night sweating (-), prolonged cough (-), bloody cough(-), reduce body weight (-) Diagnosed w/ heart disease & hypertension  hospitalised (3x)  uncontrolled afterwards  prescribed drugs Dilitiazem 3x1, Digoxin 1x1/2, Aspar 1x1, Furosemide 2x40mg, Aspilet 1x80 mg

  6. One month BHA: • Swollen legs (+), could not barely walk. History of having burnt on extremities, well treated. • Getting more thirsty  drink water more than usual, eat lots of fruit Present history of illness • 2 weeks BHA: • Swollen genital, gets friction wound, has not been treated • 1 week BHA: • Worsen shortness of breath, dry cough (+), Dyspnea at night when he sleeps, when he laying down, Cough with white sputum. Mengik (-), Chest pain (-) • 2 days BHA: • Worsen shortness of breath, high fever (+), not measured, productive cough (+) • In emergency ward  the doctor said that his eyes are yellow, patient does not notice since when

  7. Hypertension since 4 years ago Does not know having diabetes or not Lung TB (-) History of icteric/yellow (-) Asthma (-) Allergy (-) History of past illness

  8. History of hypertension (-) DM(-) Heart disease (-) Lung disease (-) Allergy (-) Asthma (-) Family history

  9. Married with one wife and has 4 children Works as a contractor Smoked for 40 years (12 cigarettes/day); Has stopped smoking since the last 4 years Consumes alcohol for more than 5 years; Has stopped since the last 10 years History of IVDU (-) Social history

  10. Consciousness : compos mentis General condition: looks severely ill Nutritional status: average (Height 172 cm; Weight 82kg; LLA 30 cm) Vital signs: Blood pressure: 110/70 mmHg Heart rate : 92 x/minute, regular, adequate Respiratory rate: 28 x/minute Temperature : 36.7 °C Physical examination

  11. Skin : looks icteric, cyanotic (-), pale (-) • Head : normocephal, black hair, hair is not easily pulled off, edema (-) • Eyes : pale conjunctiva -/-; icteric sclera +/+, DLR +/+, IDLR +/+, periorbital edema -/- • Ear : deformity -/- cerumen -/- secrete -/- • Nose : secrete (-), septum deviation (-) • Throat : Tonsils T1/T1; pharyngeal wall is not hyperemic, post nasal drip (-) • Teeth and mouth : coated tongue (-), caries dentis (+), moist mucosa

  12. Neck : JVP 5+2 cmH2O; no lymph nodes enlargement; no enlargement of thyroid gland • Heart : I : Ictus cordis not visible P: Ictus cordis is palpable on 2 fingers lateral of the left midclavicle line ICS 6 P: right heart border – 2 fingers lateral of the right sternal line Left heart border - on 2 fingers lateral of the left midclavicle line ICS 6 Heart waist – left 3rdIntercostal space, left parasternal line A: S1, 2 normal; murmur (-); gallop (+)

  13. Lungs : I: chest expansion symmetric in static and dynamic ; Emphysematous, wide intercostals space, spider navy (-), gynecomastia (-) P: Fremitus of the left lung is similar compared to the right lung P: sonor/sonor A: Vesicular +/+; crackles +/+ (ronkhi basah halus) on lung base;, rhales +/+ (rhonki basah kasar), wheezing -/-

  14. Abdomen: • I: enlarged, asymmetric • P: supple, liver is palpable 2 fingers below arcus costae, blunt, flat, tender , pain on palpation (-), spleen is not palpable, pain on epigastric area (-), hepatojugular reflex (-) • P: tympanic (+), shifting dullness (+) • A: bowel sound (+) normal Back : symmetric in static and dynamic, vesicular +/+, ronchi -/-, wheezing -/-; Nyeriketokpada CVA (-/-)

  15. Extremities : warm; CRT <2”; pitting edema +/+ ; dorsalis pedis arteries, tibialis posterior arteries, popliteal arteries are hard to palpable. Ulcus (+) on lower extremities. ABI is hard to determine; clubbing finger (-) Genitalia : edema on scrotum and penis with maceration and erythematous appearance, pus (-), blood (-)

  16. Laboratory result

  17. Blood glucose : 22/1/2011 : 14:00 – 281 mg/dl (with correctional dose) 20:00 – 240 mg/dl (with correctional dose) 02:00 – 174 mg/dl (with correctional dose)

  18. Chest x-ray PA (22/1/2011) : cardiomegaly with early sign of lung oedema and infiltrate on both lungs Chest x-ray

  19. Abdominal USG (22/1/2011) : hepatomegaly, pleura effusion dextra, ascites Electrocardiography (24/1/2011): Sinus rhytm, QRS rate 100x/minute, Left axis deviation, P wave normal, PR interval 0,16 s, QRS duration 0.08 s, Pathologic Q on V3, V4, ST-T changes (-), LBBB/RBBB, LVH/RVH (-) Interpretation: Anterior old myocardium infarction USG - ECG

  20. Congestive heart failure fc IV • Community acquired pneumonia • Type 2 diabetes mellitus • Acute on chronic kidney disease • Hypertensive heart disease with uncontrolled hypertension • Coronary arterial disease anterior • Congestive liver disease with icterus and hypoalbumin • Hyponatremia • Maseration on scrotum and penis • Diabetic ulcuscruris • Asymptomatic urinary tract infection List of problems

  21. plan • Further Diagnostic • Management • Non-Pharmacologic • Pharmacologic

  22. Quo ad vitam : dubia ad malam Quo ad functionam : malam Quo ad sananctionam : malam Prognosis

  23. Discussion

  24. Type 2 DM Man, 53 y.o Overweight Dyspnea and Fatigue Diabetic Ulcer, Skin maceration Icteric Hepatic congestion Smoker Chronic Hypertension CHF fc IV CAD hypertrophy of myofibrils  diastolic dysfunction Hyperfiltration/ hyperperfusion >> preglomerular arterioles Structural changes Pneumonia Nephrolithiasis Cardiomegaly (LVH)  HHD? << GFR Asymtomatic UTI Acute (postrenal) on CKD ? Chronic Kidney Disease Hyponaterima Edema Proteinuria

  25. List of Problems • Congestive heart failure fc IV • Community acquired pneumonia • Type 2 diabetes mellitus • Acute on chronic kidney disease • Hypertensive heart disease with uncontrolled hypertension • Coronary arterial disease anterior • Congestive liver disease with icterus and hypoalbumin • Hyponatremia • Maseration on scrotum and penis • Diabetic ulcuscruris • Asymptomatic urinary tract infection

  26. Congestive heart failure fc IV

  27. >> bronchial arteries  airway compression airway resistance Hypertension • Lower circulation  central >> pulmonary capillary pressure • DoE, PND, OT • hypertrophy of myofibrils? and diastolic dysfunction CHF Dyspnea/Fatigue • Cardiomegaly • Conduction disturbance, dilatation • respiratory alkalosis Old myocardial infarction • >> right atrial pressure • hepatic congestion  hepatocellularhypoxia  << hepatic function • Transudation  alveoli • >> hepatic veins • icteric sclera, hipoalbuminemia, hyperbilirubinemia • retention of intravascular volume • Edema, JVP>>,crackles, hepatomegaly, ascites

  28. Sensitivity, Specificity, and Predictive value of Symptoms and Physical Signs in Diagnosing CHF • Dec JW. Heart failure: a comprehensive guide to diagnosis and treatment. New York: Marcel Dekker. 2005

  29. Plan • salt restriction (< 2 g/day). • 1 portion (1325 kcal) • 45 grams of protein • 35 gram of lipid • 215 grams of carbohydrate

  30. Pharmacological Management

  31. Community Acquired Pneumonia • History • high fever • productive cough. • Physical examination • rhaleson the lung auscultation. • Lab • leukocytosis (neutophilia) • Thorax x-ray • Infiltrates on both lungs • Plan • microbiology culture and antimicrobial resistance • urea, electrolytes , liver function tests , CRP, oxygenation assessment • Empirical treatment • ceftriaxone 3x1 grIV • zytromycin 1x500 mg p.o • Antitusive • Chest Physioteraphy • Inhalation V:B:NS=1:1:1/6 H • Ceftriaxon: 3rdgen cephalosporins against gram-negatives, antipseudomonal, S. pneumonia • Azythromycin: macrolidesagainst non-tuberculousmycobacteria, H.Influenza, Cryptosporidium, toxoplasma, N. gonorrhoeae, and pathogen specific. • (ATS/IDSA) guidelines: fluoroquinolonemonotherapy and beta-lactam plus macrolidecombination • BTS definitions • Cough + other lower respiratory tract symptom • new focal chest signs on examination • systemic feature (sweating, fevers > 38, shivers, aches and pains) • no other explanation for the illness • Thorax 2001;56 (suppl IV)

  32. Type 2 DM

  33. ADA 2010 in Diabetes Care vol 33 2010

  34. Insulin in Type 2 DM • Initial therapy in type 2 DM: • lean individuals, severe weight loss • underlying renal or hepatic disease  X oral glucose-lowering agents • Infection, acutely ill • basal insulin : prevent hyperglycemia during fasting due to gluconeogenesis • prandial insulin: convert food  energy (prevent postprandial hyperglycemic) • Insulin correctional dose : hospitalized px due to some diseases or stress

  35. Diabetic foot wound care • (1) off-loading • (2) debridement • (3) wound dressings • (4) appropriate use of antibiotics • (5) revascularization, • (6) limited amputation

  36. Acute on chronic kidney disease • Diagnostic Plan: • Urin albumin/24 H (monitoring) • Ur/ Creatinine Serum • Urinalysis • Management Plan: • CHF therapy  BP control • glucose control in diabetes, • ACE-I (Captopril 2x12.5 mg/day) • Dietary protein restriction (0.8 gr/KgBW/day) • Consultation: Urology Dept

  37. Development of DM Nephropathy • Ur: 67 mg/dl • Cr: 1.2 mg/dl • eGFR : 67.58 • Proteinuria : +++

  38. ACE-Inhibitor Roles CHF & Hypertension  << afterload & preload , antiremodelling Diabetic Nephropathy  << protein loss  << glomerular efferent arteriolar resistance  << intraglomerularcapillary pressure

  39. HHD due to uncontrolled hypertension dd / CORONARY ARTERIAL DISEASE Diagnostic Plan: lipid profile, funduscopy, echocardiography, corangiography Management Plan: bed rest, venflon, diet Jantung 2100 kcal/day (soft), Captopril 2x12.5 mg, Furosemide 3x40mg, KSR 2x1 tab.aspilet 1x80 mg, omeprazole 2x20 mg,

  40. Hypertension management (jnc 7) ADA 2010: Aspirin (75–162 mg/ day)  primary prevention for DM + CV risks 1. men 50 years of age women 60 years family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria ASA : blocking COX blocking thromboxanesynthase inactivate the production thrombin  X Platelet aggregation

  41. Congestive liver disease Diagnostic Plan: HbsAg and anti HCV Management Plan: CHF Treatment Hepatoprotector?? CHF Patient with congestive signs

  42. Hyponatremia - UTI Hyponatremia • History: low intake, nausea, vomiting (-) • PE: edema • Laboratory Na: 129 mmeq/l. • Management: • Ur/Cr/Electrolyte • CHF treatment Asymptomatic UTI • History: pain during urination, polachysuria, frequency of urination, incontinencia (-) • PE: CVA pain (-), fever (-) • Urine Exam: pH 5 / protein +++ / keton (-) / erythrocyte 20-22 / bacteria +/ leucocytes 2-3. • Management: • repeated CBC, • urinalysis • Ur/Cr. • Ceftriaxone3 x 1 gram. DilusionalHyponatremia: HF edematous state  ECF vol >> Related to DM & nephrolithiasis

  43. TerimaKasih THANK YOU

  44. Hunt SA, et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in adult. Circulation 2005;112;e154-e235). • Tendera M. Epidemiology, treatment, and guidelines for the treatment of heart failure in Europe. Eur Heart J Suppl 2005:7(Supplement J);J5–J9 • Fauci AS, Kasper DL, Longo DL, Braunwald E, Hauser SL, Jameson JL, et al. Harrison’s principles of internal medicine 17th ed. New York: The McGraw-Hill; 2008. • Complete Report. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. US Department Health and Human Services • Siswanto BB, Dharma S. PedomanTatalaksanaPenyakitKardiovaskulardi Indonesia. Jakarta: PERKI. 2009. • Lullmann H, et al. Color Atlas of Pharmacology 2nd edition. New York: Thieme. 2000 • Katzung BG. Basic and Clinical Pharmacology 10th ed. Philadeplhia: McGraw-Hill. 2006 • Buku Ajar IPD. • Dec JW. Heart failure: a comprehensive guide to diagnosis and treatment. New York: Marcel Dekker. 2005 • Wang TJ et al. Factors influencing heart failure patient’ sleep quality. J Adv Nursing. 2010 66;6:1730-9 • Frei CR. et al. Medical resource utilization among community-acquired pneumonia patients initially treated with levofloxacin 750 mg daily versus ceftriaxone 1000 mg plus azithromycin 500 mg daily: A US-based study. Current Medical Research and Opinion.2009:25;4552-559 • Terapi Insulin • Guidelines and Protocols Advisory Committee. Chronic Kidney Disease: Identification, Evealuation, and Management of Patients. British Columbia Medical Association.2008 • (Levey AS. Clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification.K/DOQI.2002). • Chronic Kidney Disease in Adults: UK Guidelines for Identification, Management and Referral. Joint Specialty Committee on Renal Disease. 2005 REFERENCES

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