Download - Lapkas 2 Dr.toton II
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PRESENTASI KASUS II
Presentan : Ikhwanul KamilPembimbing: dr. Toton Suryotono, Sp.PD
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Identitas Pasien dan Keluhan Utama
Tn. Apep, 62 tahun, seorang petani dengan riwayat penyakit ginjal 2 tahun lalu datang ke IGD RSUD Cianjur dengan keluhan sesak napas sejak 2 hari SMRS
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Riwayat Penyakit Sekarang
Sehari-hari pasien bekerja sebagai petani dengan pola makan yang tidak teratur dan sering mengkonsumsi goreng-gorengan. Pasien memiliki riwayat hipertensi dan penyakit ginjal sebelumnya + 2 tahun yang lalu. Pasien mengaku Sudah melakukan cuci darah 1x.
Sejak 2 minggu SMRS pasien mengeluh sesak napas. Sesak dirasakan makin memberat terutama 2 hari SMRS. Sesak lebih berat setelah beraktivitas biasa dan membaik ketika istirahat. Pasien juga mengaku sesak dirasakan memberat ketika berbaring dibandingkan duduk. Pasien sering terbangun pada malam hari karena sesak napas, sesak dirasakan berkurang bila tidur menggunakan 3 bantal.
Pada saat sesak napas tidak disertai bunyi ngik-ngik, pasien juga tidak merasa sesak nafas apabila terkena debu, bulu ataupun cuaca dingin. Pasien mengaku keluhan sesak napas disertai nyeri pada ulu hati (+), nyeri dirasakan terus-menerus, nyeri terasa seperti diremas-remas. Pasien mengaku lengan dan tungkai membengkak.
Pada tanggal 24 Januari 2016, pasien dibawa ke IGD RSUD Cianjur dengan keluhan sesak napas sejak 2 hari yang lalu.
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Pemeriksaan Fisik
• Pasien tampak sakit sedang dengan kesadaran compos mentis. Tekanan darah 160/100 mmHg, Nadi 96 x/m, Pernapasan 26 x/m, Suhu 36,8 oC.
• Pada pemeriksaan fisik ditemukan konjungtiva anemis, JVP meningkat + 3 cm. Pada Thorax ditemukan rales positif. Pada abdomen ditemukan cembung, nyeri tekan epigastrium. Pada ekstremitas akral hangat dan ditemukan ada tanda-tanda edema pada lengan dan tungkai. Pemeriksaan lain dalam batas normal.
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Tanggal Pemeriksaan Hasil Nilai Rujukan Satuan24 Jan 2016
Hematologi LengkapHb HematokritEritrositLeukositTrombositMCVMCHMCHCRDW-SDDifferential
LYM %MXD %NEU %EOS %BAS %
AbsolutLYM %MXD %NEU %EOS %BAS %
7.6*23.7*3.08*12.300*129.000*76.9*24.7*32.1*47.2 9.6*8.881.2*0.2*0.2 1.181.0810.0*0.020.02
12-1637-474.2-5.44800-10.800150.000-450.00080-9427-3133-3737-54 26-360-1140-701-3<1 1.00-1.430-1.21.8-7.60.02-0.500.00-0.10
g/dl%106/uL/uL/uLfLpg%fL %%%%% 103/uL103/uL103/uL103/uL103/uL
KIMIA KLINIKGlukosa Rapid Sewaktu
79
<180
mg/dL
Pemeriksaan Penunjang
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`EKG Tanggal 24 januari 2016
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DAFTAR MASALAH
• 1. Decompensatio cordis fc II-III grup C• 2. Suspek Chronic Kidney Disease
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ASESMEN DAN RENCANA PELAYANAN
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Diagnosis 1
1. Dekompensasi Cordis FC III Stage C
Dekompensasi kordis adalah kegagalan jantung dalam upaya untuk mempertahankan peredaran darah sesuai dengan kebutuhan tubuh. Dekompensasi cordis adalah suatu keadaan dimana terjadi penurunan kemampuan fungsi kontraktilitas yang berakibat pada penurunan fungsi pompa jantung.
HF is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood.
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Kriteria Mayor : Kriteria minor :
o Paroksismal nocturnal dispneu o Edema ekstremitas
o Distensi vena leher o Batuk malam hari
o Ronki paru o Dispnea d’effort
o Kardiomegali o Hepatomegali
o Gallop S3 o Efusi pleura
o Peninggian tekanan vena
jugularis
o Penurunan kapasitas vital 1/3 dari
normal
o Refluks hepatojugular o Takikardia
Pada pasien didapatkan 2 kriteria mayor dan 2 kriteria minor, dinyatakan (+) dekomp cordis menurut kriteria Frammingham.
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Klasifikasi dan severity
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Kapasitas Fungsional Klasifikasi New York Heart Association Penilaian Objektif
Class I Pasien dengan penyakit jantung tanpa keterbatasan pada aktivitas fisik. Aktivitas fisik biasa tidak menyebabkan keletihan, sesak, atau nyeri angina
Class II Pasien dengan penyakit jantung dengan keterbatasan ringan aktivitas fisik. Aktivitas fisik biasa mengakibatkan kelemahan, sesak, atau nyeri angina; yang hilang dengan istirahat
Class III Pasien dengan penyakit jantung dengan keterbatasan pada aktivitas fisik. Sedikit aktivitas menyebabkan kelemahan, sesak, palpitasi atau nyeri angina; yang hilang dengan istirahat
Class IV Pasien dengan penyakit jantung dengan ketidakmampuan untuk melakukan aktivitas fisik apapun. Keluhan gagal jantung atau sindroma angina masih dirasakan meskipun saat istirahat. Jika melakukan aktivitas fisik, maka rasa tidak nyaman bertambah.
Pada pasien mencangkup fungsional class III menurut NYHA.
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Klasifikasi Berdasarkan American Collage of Cardilogy and The American Heart Association
Stadium A : Berisiko tinggi menderita gagal jantung tetapi tanpa kelainan struktur jantung atau tanpa adanya keluhan gagal jantung
Stadium B : Adanya penyakit struktur jantung dengan keluhan atau tanda gagal jantung
Stadium C : Adanya penyakit struktur jantung dengan keluhan atau tanda gagal jantung, hipoperfusi
Stadium D : Gagal jantung refrakter, kongesti paru dan hipoperfusi
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ETIOLOGI
Sindrom koroner akut : infark miokard / angina pectoris tidak stabil dengan iskemia yg bertambah luasKomplikasi kronik infark miokard akut
Infark ventrikel kanan
Krisis hipertensi
Aritimia akut : takikardia ventrikular, fibrilasi ventricular, fibrilasi atrial/fluter atrial, takikardia supraventikularEndokarditis / ruptur korda tendinae, perburukan regurgitasi katup yang sudah adaStenosis katup aorta berat
Miokarditis berat akut
Tamponade jantung
Diseksi aorta
Kardiomiopati pasca melahirkan
Infeksi
Penurunan fungsi ginjal
Asma
Penyalahgunaan obat
Penggunaan alkohol
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Medikamentosa yang diberikan:1. Decompensatio cordis FC II grup C- IVFD D5% 500cc/24 jam- 02 4l/mnt nasal kanul- Furosemid 2x40mg- ISDN 3x5mg
Penatalaksanaan
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2. Chronic Kidney Disease
• Essentials of diagnosis- Decline in the GFR over months to years- Persistent proteinuria or abnormal renal morphology may be
present- Hypertension in most cases- Symptoms and signs of uremia when nearing end-stage disease- Bilateral small or echogenic kidneys on ultrasound in advance
diseaseIn the early stages, CKD is asymptomatic. Symptoms develop slowly with the progressive decline in GFR, are non spesific, and do not manifest until kidney disease is far advance (GFR < 5-10mL/min/1.73m²).General symptoms of uremia may include fatigue and weakness;anorexia, nausea, vomiting, and a metallic taste in the mouth are also common. Patients or family members may report irritability, memory impairment, insomnia, restless legs, paresthesias and twitching. Generalized pruritus without rash may occur. The most common physical finding in CKD is hypertension.
CMDT 2015
Diagnosis 2
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CKD is defined as abnormalities of kidney structure or function, present for >3 months, with implications for health.
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Klasifikasi dan severity
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CKD is usually defined by an abnormal GFR persisting for at least 3 months. Persistent proteinuria or abnormalities on renal imaging (eg. Polycystic kidneys) are also diagnostic of CKD, even when estimated GFR is normal.
Major causes of chronic kidney disease
Glomerular diseases-primary glomerular diseases
Focal and segmental glomerulosclerosis
Membranoproliferative glomerulonephritisIgA nephropathy
Membranous nephropathyAlport syndrome (hereditary nephritis)
-secondary glomerular diseasesDiabetic nephropathy
AmyloidosisPostinfectious glomerulonephritis
HIV-associated nephropathyCollagen-vascular diseases (eg. SLE)
HCV-associated membranoproliferative glomerulonephritis
Tubulointerstitial nephritisDrug hypersensitivity
Heavy metalsAnalgesic nephropathySickle cell nephropathy
idiopathic
Major causes of chronic kidney diseaseCystic diseases
Polycystic kidney diseaseMedullary cystic disease
Obstructive nephropathiesProstatic diseaseNephrolithiasis
Retroperitoneal fibrosis/tumorCongenital
Vascular diseasesHypertensive nephrosclerosis
Renal artery stenosis
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Medikamentosa yang diberikan:2. Chronic Kidney Disease- Bicnat 3x1- Asam folat 3x1
- Cek Ureum , Kreatinin
Penatalaksanaan
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CATATAN PERKEMBANGAN
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Catatan PerkembanganTanggal: 25/01/16
Subjective Objective
Sesak napas (+) 160/100 mmHg
Nyeri perut (+) 92 x/m
Mual (+) 26 x/m
Nyeri kepala (+) 36,9 c
Muntah (-) CA(+/+)
JVP meningkat
Rales (+/+)
NTE (+)
Edema ekst. atas dan bawah (+/+)
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Tanggal Pemeriksaan Hasil Nilai Rujukan
Satuan
25 Jan 2016
KIMIA KLINIKFungsi GinjalUreumKreatinin ElektrolitNatrium (Na)Kalium (K)Chlorida (Cl)
167.5*9.1* 136.34.53102
10-500.5-1.0 135-1483.50-5.3098-107
mg%mg% mEq/LmEq/LmEq/L
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Assessment Plan1 Decomp cordis FC II group C - IVFD D5% 500cc/24 jam
- 02 4l/mnt nasal kanul- Furosemid 2x40mg- ISDN 3x5mg
2 CKD - Bicnat 3x1- Asam folat 3x1
3 Hipertensi grade II - Amlodipin 1x10 mg
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Catatan PerkembanganTanggal: 30/01/16
Subjective Objective
Sesak napas (+) 140/70 mmHg
Nyeri perut (+) 92 x/m
Mual (+) 24 x/m
Nyeri kepala (-) 36,8 c
Muntah (-) CA (+/+)
BAK sedikit JVP meningkat
Rales (+/+)
NTE (+)
Edema ekst. atas dan bawah (+/+)
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Tanggal Pemeriksaan Hasil Nilai Rujukan Satuan30 Jan 2016
Hematologi LengkapHb HematokritEritrositLeukositTrombositMCVMCHMCHCRDW-SDPDWMPVDifferential
LYM %MXD %NEU %EOS %BAS %
AbsolutLYM %MXD %NEU %EOS %BAS %
7.0*21.1*2.87*7.700241.00073.5*24.4*33.248.311.19.7 5.8*9.583.9*0.5*0.3 0.44*0.736.420.040.02
12-1637-474.2-5.44800-10.800150.000-450.00080-9427-3133-3737-549-148-12 26-360-1140-701-3<1 1.00-1.430-1.21.8-7.60.02-0.500.00-0.10
g/dl%106/uL/uL/uLfLpg%fLfLfL %%%%% 103/uL103/uL103/uL103/uL103/uL
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30 Jan 2016
KIMIA KLINIKGlukosa Rapid Sewaktu
120
<180
mg/dL
Fungsi GinjalUreumKreatinin
179.5*10.0*
10-500.5-1.0
mg%mg%
ELEKTROLITNatrium (Na) Kalium (K)Calcium ion
119.6*4.290.97*
135-1483.50-5.301.15-1.29
mEq/LmEq/Lmmol/L
Lanjutan
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Rontgen Thorax
• Kardiomegali dengan bendungan paru
• Tidak tampak TB paru aktif• Diafragma, sinuses, pleura dan
skeletal tampaknya masih baik
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Assessment Plan1 Decomp cordis FC II group C
tidak ada perbaikan- IVFD D5% 500cc/24 jam- 02 4l/mnt nasal kanul- Furosemid 2x40mg- ISDN 3x5mg
2 CKD perburukan - Bicnat 3x1- Asam folat 3x1
3 Hipertensi grade II TD tercapai target
- Amlodipin 1x10 mg
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Catatan PerkembanganTanggal: 06/02/16
Subjective Objective
Sesak napas (+) 110/60 mmHg
Nyeri perut (+) 92 x/m
Mual (-) 24 x/m
Nyeri kepala (-) 36,8 c
Muntah (-) CA (+/+)
BAK sedikit JVP meningkat
Rales (+/+)
NTE (+)
Edema ekst. bawah (+/+)
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Tanggal Pemeriksaan Hasil Nilai Rujukan
Satuan
06 Feb 2016
KIMIA KLINIKFungsi GinjalUreumKreatinin ElektrolitNatrium (Na)Kalium (K)Chlorida (Cl)
237.7*14.8* 126.6*4.471.03*
10-500.5-1.0 135-1483.50-5.3098-107
mg%mg% mEq/LmEq/LmEq/L
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Assessment Plan1 Decomp cordis FC II group C ec
CAD tidak ada perbaikan- IVFD D5% 500cc/24 jam- 02 4l/mnt nasal kanul- Furosemid 2x40mg- ISDN 3x5mg
2 CKD perburukan - Bicnat 3x1- Calos 3x1- Hitung urine output- R/ USG upper & lower
abdomen- R/cek urine lengkap
3 Hipertensi grade II TD tercapai target
- Amlodipin 1x10 mg
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Catatan PerkembanganTanggal: 10/02/16
Subjective Objective
Sesak napas (+) 140/70 mmHg
Nyeri perut (+) 88 x/m
Mual (-) 24 x/m
Nyeri kepala (-) 36,8 c
Muntah (-) CA (+/+)
BAK sedikit JVP meningkat
Rales (+/+)
NTE (+)
Edema ekst. Atas dan bawah (-/-)
Urine output 1300/24 jam
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Tanggal Pemeriksaan Hasil Nilai Rujukan Satuan10 Feb 2016Jam 06.26 WIB
Hematologi LengkapHb HematokritEritrositLeukositTrombositMCVMCHMCHCRDW-SDPDWMPVDifferential
LYM %MXD %NEU %EOS %BAS %
AbsolutLYM %MXD %NEU %EOS %BAS %
6.6*20.1*2.65*16.700*275.00075.7*24.9*32.9*57.6*16.1*8.6 6.3*2.990.4*0.2*0.2 1.040.5015.06*0.030.04
12-1637-474.2-5.44800-10.800150.000-450.00080-9427-3133-3737-549-148-12 26-360-1140-701-3<1 1.00-1.430-1.21.8-7.60.02-0.500.00-0.10
g/dl%106/uL/uL/uLfLpg%fLfLfL %%%%% 103/uL103/uL103/uL103/uL103/uL
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Tanggal Pemeriksaan Hasil Nilai Rujukan
Satuan
10 Feb 2016Jam 08.45 WIB
URINEKimia UrinWarnaKejernihanBerat JenispHNitritProtein UrinGlukosa (reduksi)KetonUrobilinogenBilirubinEritrositLeukosit MikroskopisLeukositEritrositEpitel KristalSilinderLain-lain
KuningJernih1.0108.0Positif*25/1+*NormalNegatifNormalNegatif250/5+*500/3+* BanyakBanyak1-3NegatifNegatifBakteri (+)
KuningJernih1.013-1.0304.6-8.0NegatifNegatifNormalNegatifNormalNegatifNegatifNegatif 1-40-1 NegatifNegatifNegatif
mg/dLmg/dLmg/dLUEmg/dL/uL/uL /LPB/LPB /LPK
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Tanggal Pemeriksaan Hasil Nilai Rujukan Satuan10 Feb 2016Jam 11.03 WIB
Hematologi LengkapHb HematokritEritrositLeukositTrombositMCVMCHMCHCRDW-SDPDWMPVDifferential
LYM %MXD %NEU %
AbsolutLYM %MXD %NEU %
6.8*21.5*2.79*14.600*281.00077.1*24.4*31.6*59.6*12.89.6 6.5*4.089.5* 0.90*0.6013.10*
12-1637-474.2-5.44800-10.800150.000-450.00080-9427-3133-3737-549-148-12 26-360-1140-70 1.00-1.430-1.21.8-7.6
g/dl%106/uL/uL/uLfLpg%fLfLfL %%% 103/uL103/uL103/uL
Morfologi Darah TepiEritrosit : Anisokrom, aniso-poikilositosis (target cel, burr cel). Tidak ditemukan normoblastLeukosit : Jumlah leukosit meningkat, neutrofilia.Trombosit : Kelompok trombosit cukupKesan : Anemia ec. Penyakit kronik
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Assessment Plan1 Decomp cordis FC II group C ec
CAD tidak ada perbaikan- IVFD D5% 500cc/24 jam- 02 4l/mnt nasal kanul- Furosemid 2x40mg- ISDN 3x5mg
2 CKD stage V perburukan - Bicnat 3x1- Calos 3x1- Hitung urine output- R/ USG upper & lower
abdomen3 Hipertensi grade II TD tercapai
target- Amlodipin 1x10 mg
4 ISK - Ceftriaxone 3x1gr- PCT 3x500mg (prn)
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Catatan PerkembanganTanggal: 11/02/16
Subjective Objective
Sesak napas (+) 150/90 mmHg
Nyeri perut (-) 92 x/m
Mual (-) 24 x/m
Nyeri kepala (-) 36,8 c
Muntah (-) CA (-/-)
BAK sedikit JVP meningkat
Rales (+/+)
Edema ekst. Atas dan bawah (-/-)
Urine output 900/24 jam
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Tanggal Pemeriksaan Hasil Nilai Rujukan Satuan11 Feb 2016
Hematologi LengkapHb HematokritEritrositLeukositTrombositMCVMCHMCHCRDW-SDPDWMPVDifferential
LYM %MXD %NEU %EOS %BAS %
AbsolutLYM %MXD %NEU %EOS %BAS %
7.8*23.5*3.41*12.300*274.00068.9*22.9*33.250.711.010.2 9.5*10.577.8*1.90.3 1.161.29*9.54*0.230.04
12-1637-474.2-5.44800-10.800150.000-450.00080-9427-3133-3737-549-148-12 26-360-1140-701-3<1 1.00-1.430-1.21.8-7.60.02-0.500.00-0.10
g/dl%106/uL/uL/uLfLpg%fLfLfL %%%%% 103/uL103/uL103/uL103/uL103/uL
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USG ABDOMEN• Proses kronis ginjal bilateral
ditandai ukuran ginjal yang mengecil echogenitas parenkim meningkat
• Multipel cysta simple ginjal kanan dan kiri
• Efusi pleura bilateral• Vesica urinaria normal
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Assessment Plan1 Decomp cordis FC II group C ec
CAD tidak ada perbaikan- IVFD D5% 500cc/24 jam- 02 4l/mnt nasal kanul- Furosemid 2x40mg- ISDN 3x5mg
2 CKD stage V perburukan - Bicnat 3x1- Calos 3x1- Asam folat 3x1- Hitung urine output
3 Hipertensi grade II TD tercapai target
- Amlodipin 1x10 mg
4 ISK - Ceftriaxone 3x1gr- PCT 3x500mg (prn)
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Catatan PerkembanganTanggal: 16/02/16
Subjective Objective
Kesadaran : GCS = E3 M5 V2
Sesak napas (+) 76/44 mmHg
Nyeri perut (-) 92 x/m
Mual (-) 26 x/m
Nyeri kepala (-) 36,8 c
Muntah (-) CA (-/-)
BAK sedikit JVP meningkat
Rales (+/+)
Edema ekst. Atas dan bawah (-/-)
Urine output 600/24 jam
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Tanggal Pemeriksaan Hasil Nilai Rujukan Satuan16 Feb 2016
Hematologi LengkapHb HematokritEritrositLeukositTrombositMCVMCHMCHCRDW-SDPDWMPVDifferential
LYM %MXD %NEU %EOS %BAS %
AbsolutLYM %MXD %NEU %EOS %BAS %
7.8*24.8*3.35*10.400185.00074.1*23.3*31.4*66.5*16.1*9.2 8.9*3.885*1.80.5 0.92*0.408.85*0.190.06
12-1637-474.2-5.44800-10.800150.000-450.00080-9427-3133-3737-549-148-12 26-360-1140-701-3<1 1.00-1.430-1.21.8-7.60.02-0.500.00-0.10
g/dl%106/uL/uL/uLfLpg%fLfLfL %%%%% 103/uL103/uL103/uL103/uL103/uL
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Assessment Plan1. Penurunan kesadaran ec susp.
Gangguan elektrolit dd hipoglikemi
- Cek analycer, cek GDS, elektrolit
1 Decomp cordis FC II group C ec CAD tidak ada perbaikan
- IVFD D5% 500cc/24 jam- 02 4l/mnt nasal kanul- Furosemid 2x40mg- ISDN 3x5mg
2 CKD stage V perburukan - Bicnat 3x1- Calos 3x1- Asam folat 3x1- Hitung urine output- R/ USG upper & lower
abdomen- R/cek urine lengkap
3 ISK - Ceftriaxone 3x1gr- PCT 3x500mg (prn)
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Catatan PerkembanganTanggal: 16/02/16 jam 20.15
Subjective Objective
Kesadaran : GCS = E4 M2 V1, pupil isokor 2,5mm , RC (+/+)
Sesak napas (+) 76/44 mmHg
Nyeri perut (-) 73 x/m
Mual (-) 24 x/m
Nyeri kepala (-) 36,8 c
Muntah (-) CA (-/-)
BAK sedikit JVP meningkat
Rales (+/+)
Edema ekst. Atas dan bawah (-/-)
Urine output 600/24 jam
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Lanjutan
16 Feb 2016
KIMIA KLINIKGlukosa Rapid Sewaktu
73
<180
mg/dL
Fungsi GinjalUreumKreatinin
329.4*17.2*
10-500.5-1.0
mg%mg%
ELEKTROLITNatrium (Na) Kalium (K)Calcium ion
139.45.82*1.00*
135-1483.50-5.301.15-1.29
mEq/LmEq/Lmmol/L
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Assessment Plan1. Penurunan kesadaran ec susp.
Gangguan elektrolit- 02 5l/mnt nasal kanul- Bila MAP , 65 Dobutamin 5-10 Dopamin 5-10
2 Decomp cordis FC II group C tidak ada perbaikan
- IVFD D5% 500cc/24 jam- 02 4l/mnt nasal kanul- Furosemid 2x40mg- ISDN 3x5mg
3 CKD stage V tidak ada perbaikan
- Bicnat 3x1- Calos 3x1- Asam folat 3x1- Hitung urine output
4 ISK - Ceftriaxone 3x1gr- PCT 3x500mg (prn)
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HF significantly decreases health-related quality of life (HRQOL), especially in the areas of physical functioning and vitality (66,67). Women with HF have consistently been found to have poorer HRQOL than men (67,70).
Patients hospitalized for HF are at high risk for all-cause rehospitalization, with a 1-month readmission rate of 25% (61). Although survival has improved, the absolute mortality rates for HF remain approximately 50% within 5 years of diagnosis (53,59).
In the ARIC study, the 30-day, 1-year, and 5-year case fatality rates after hospitalization for HF were 10.4%, 22%, and 42.3%, respectively (58). In another population cohort study with 5-year mortality data, survival for stage A, B, C, and D HF was 97%, 96%, 75%, and 20%, respectively (47).
PROGNOSIS
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PROGNOSISIn predicting risk for outcome of CKD, identify the following variables: 1) cause of CKD; 2) GFR category; 3) albuminuria category; 4) other risk factors and comorbid conditions.
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WASSALAMUALAIKUM