CASE PRESENTATIONFATIGUE

GROUP A M Hafiizh – Bonita Effendi – Adly Nanda – Dini Irawan – Anita Santoso - Zanetha – Genesius Nene

Supervisor : Dr. Ginova Nainggolan, SpPD-KGHDr. Zunilda, SpFK

Anamnesis and physical examination were conducted on January 24th, 2011

CASE ILLUSTRATION

IDENTITY OF THE PATIENT 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

CHIEF COMPLAINT Patient complained of having shortness

of breath since 2 days before hospital admission.

PRESENT HISTORY OF ILLNESS4 years BHA :Diagnosed of having hypertension (systolic pressure 190 mmHg); headache (-), reduced consciousness (-), ches pain (-), slurred speech (-) uncontrolledEasily 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

PRESENT HISTORY OF ILLNESS 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

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

HISTORY OF PAST ILLNESS Hypertension since 4 years ago Does not know having diabetes or not Lung TB (-) History of icteric/yellow (-) Asthma (-) Allergy (-)

FAMILY HISTORY History of hypertension (-) DM(-) Heart disease (-) Lung disease (-) Allergy (-) Asthma (-)

SOCIAL HISTORY 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 (-)

PHYSICAL EXAMINATION 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

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

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 lineLeft heart border - on 2 fingers lateral of the left midclavicle line ICS 6Heart waist – left 3rd Intercostal space, left parasternal line A: S1, 2 normal; murmur (-); gallop (+)

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 -/-

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 (+) normalBack :

symmetric in static and dynamic, vesicular +/+, ronchi -/-, wheezing -/-; Nyeri ketok pada CVA (-/-)

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 (-)

LABORATORY RESULTLaboratory Examination 21/1/2011 24/1/2011

Hemoglobin 16.1 g/dl 15.3 g/dl

Hematocrit 49 % 47%

Leukocytes 11900 /uL 8160/uL

Thrombocytes 274000 /uL 244000/uL

ESR

MCV 85 86.2 fl

MCH 28 28.1 pg

MCHC 32.6 g/dl

Diff. count -/-/3/85/10/2

Ureum 67 mg/dl 104 mg/dl

Creatinine 1.2 mg/dl 1.5 mg/dl

SGOT 38 193 u/L

SGPT 66 151 u/L

Albumin 2.7

Total bilirubin 8.6 (0.3-1.1) 7.19 mg/dl

Direct bilirubin 6.9 (0-0.3) 5.77 mg/dl

Indirect bilirubin 2.1 1.42 mg/dl

Random blood glucose 259

Na / K / Cl 129 / 4.6 / 97

Blood Gas Analysis

pH 7.519 7.449

pCO2 27.6 (35-45) 36.4

pO2 107.8 89.3

sO2 98.9 97.2%

HCO3 22.7 (22-26) 25.2 mmol/L

Urine

pH 5

Berat jenis 1.03

Protein +++

Glucose -

Keton -

Erythrocyte ++

Bilirubin +

Urobilinogen 2

Leucocyte 2-3

Erythrocyte 20-22

Bacteria +

Triglyceride 90 mg/dl

Total cholesterol 122 mg/dl

HDL cholesterol 15 mg/dl

LDL cholesterol 89 mg/dl

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)

CHEST X-RAY Chest x-ray PA (22/1/2011) :

cardiomegaly with early sign of lung oedema and infiltrate on both lungs

USG - ECG 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

LIST OF PROBLEMS

1. Congestive heart failure fc IV2. Community acquired pneumonia3. Type 2 diabetes mellitus4. Acute on chronic kidney disease5. Hypertensive heart disease with uncontrolled

hypertension6. Coronary arterial disease anterior7. Congestive liver disease with icterus and

hypoalbumin8. Hyponatremia9. Maseration on scrotum and penis10. Diabetic ulcus cruris 11. Asymptomatic urinary tract infection

PLAN Further Diagnostic Management

Non-Pharmacologic Pharmacologic

PROGNOSIS Quo ad vitam : dubia ad malam Quo ad functionam : malam Quo ad sananctionam : malam

DISCUSSION

Man, 53 y.o Overweight

Chronic Hypertens

ion

Chronic Kidney Disease

Cardiomegaly (LVH)

HHD?

hypertrophy of myofibrils

diastolic dysfunction

Dyspnea and Fatigue

CHF fc IV

>> preglomerular

arteriolesStructural changes

<< GFR

Type 2 DM

Smoker

Hyperfiltration/ hyperperfusion

Diabetic Ulcer, Skin maceration

CAD

Pneumonia

EdemaProteinuria

Hyponaterima

Nephrolithiasis

Asymtomatic UTI

Hepatic congestio

n

Icteric

Acute (postren

al) on CKD ?

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 ulcus cruris Asymptomatic urinary

tract infection

CONGESTIVE HEART FAILURE FC IV

History

exertional dyspneaparoxysmal

nocturnal dyspneaOrthopnea

Edemachronic

hypertension shortness of breath

all day long, including at rest

PEperipheral pitting

edema icteric sclera

JVP>>

cardiomegaly

crackles

hepatomegaly,

ascites,

Supporting

hypoalbuminemia

hyperbilirubinemia

hyponatremia

respiratory alkalosis

ECG: Inferior OMIChest x-ray :

cardiomegaly, lung oedema

Abd USG: hepatomegaly, pleura effusion dextra, ascites

CHF

Hypertension

Old myocardial infarction

DoE, PND, OTLower circulation

central >> pulmonary capillary

pressure

>> bronchial arteries airway

compression airway resistance

Edema, JVP>>,crackles, hepatomegaly,

ascites

icteric sclera, hipoalbuminemia, hyperbilirubinemia

hepatic congestion hepatocellular hypoxia <<

hepatic function

>> right atrial pressure

hypertrophy of myofibrils? and

diastolic dysfunction

Transudation alveoli

>> hepatic veinsretention of

intravascular volume

Cardiomegaly

respiratory alkalosis

Dyspnea/Fatigue Conduction

disturbance, dilatation

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

PLANNon-

pharmacologic:

Bedrest (semifowler)

Soft “Diet Jantung” 2100kcal

IV line

oxygen 3 l/m NC

fluid restriction (800 cc/24 hour)

fluid balance (-500 cc/24 hour)

Diagnostic

Lipid profile risk factors & complications (CVD, MI, dyslipidemia)

echocardiography + Doppler Structure & function (LVEF, LV size, wall thickness, and valve function)

Coronary arteriography

• salt restriction (< 2 g/day).

• 1 portion (1325 kcal)• 45 grams of protein• 35 gram of lipid• 215 grams of

carbohydrate

PHARMACOLOGICAL MANAGEMENT

•inhibits Na+/K+/2Cl– cotransport >> excretion of Na+ and H2O << plasma volume.furosemide 3x40

mg IV(40-240 mg/day)

•vasodilator effects reduce peripheral resistance << afterload

•aldosterone inhibition << salt and water retention << preload

•Anti remodellingcaptopril 2x12.5 mg p.o

(adjusted dose for RF)

•prevent hypokalemia (side effect of Furosemide)

KSR 2x1 tab p.o

COMMUNITY ACQUIRED PNEUMONIA History

high fever productive cough.

Physical examination rhales on 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 gr IV zytromycin 1x500 mg

p.o Antitusive Chest Physioteraphy Inhalation

V:B:NS=1:1:1/6 H

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)

•Ceftriaxon: 3rd gen cephalosporins against gram-negatives, antipseudomonal, S. pneumonia•Azythromycin: macrolides against non-tuberculous mycobacteria, H.Influenza, Cryptosporidium, toxoplasma, N. gonorrhoeae, and pathogen specific. (ATS/IDSA) guidelines: fluoroquinolone monotherapy and beta-lactam plus macrolide combination

TYPE 2 DM

Historypolyuria,

polyphagia, and polydypsiaunhealed ulcus in

the cruris and scrotum

numbness ,hypestesia

fatigue and sleepyED: RBG >

200mg/dl (2x)

PE

BMI : 27.7 kg/m2

Ulcers (scrotum & cruris)ABI: ?

Supporting

RBG(mg/dl) : 259 281 174 240

•HbA1c, lipid profile, ankle brachial index, funduscopy

Diagnostic Plan

•bed rest, diet (soft food) 2100 kcal/day, and Insulin sliding scale per 6 hours.

Management

ADA 2010 in Diabetes Care vol 33 2010

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

RPG (mg/dl)

Insulin (IU)

200 0201-250 5251-300 10301-350 15> 350 20

DIABETIC FOOT WOUND CARE (1) off-loading (2) debridement (3) wound dressings (4) appropriate use

of antibiotics (5)

revascularization, (6) limited

amputation

ACUTE ON CHRONIC KIDNEY DISEASE History

HypertensionPolyuria,

polydipsia, polyphagia

PE

BMI : 27.7 kg/m2

CVA pain (-)

Lab & Rad

Ur: 67 mg/dl/Cr: 1.2 mg/dl

eGFR : 67.58 mL/min/1.73m2

Proteinuria : +++

Hematuria : ++

Nephrolithiasis

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

Diabetic NephropathyDM

Ur: 67 mg/dlCr: 1.2 mg/dleGFR : 67.58

Proteinuria : +++

Acute on CKD : rapid decline in glomerular filtration rate (GFR) over hours to days

Pre renal : Low cardiac ouput state :worsening

CHFrenal : Malignant

hypertension?Post renal:

nephrolithiasis

CKD Definition Stage II (Kidney Damage + GFR 60-89)

eGFR < 60mL/min for> 3 months

evidence of kidney damage (pathologic abnormalities or markers

of damage blood/urine tests/imaging studies

DEVELOPMENT OF DM NEPHROPATHY

Ur: 67 mg/dlCr: 1.2 mg/dleGFR : 67.58Proteinuria : +++

ACE-INHIBITOR ROLES

1. CHF & Hypertension << afterload & preload , antiremodelling

2. Diabetic Nephropathy << protein loss << glomerular efferent arteriolar resistance << intraglomerular capillary pressure

HHD DUE TO UNCONTROLLED HYPERTENSION DD / CORONARY ARTERIAL DISEASE

History

hypertension since 4 years (uncontrolled)

history : 190mmHg systolic pressure.

chest pain, hemiparesis, slurred speech, headache (-)

PEBP:

110/70mmHgCardiomegaly

Gallopedema

Supporting

ECG: Inferior OMIChest x-ray :

cardiomegaly CTR> 60%

Diagnostic Plan:lipid profile, funduscopy, echocardiography, corangiographyManagement 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,

HYPERTENSION MANAGEMENT (JNC 7)

ADA 2010: Aspirin (75–162 mg/day) primary prevention for DM + CV risks 1. men 50 years of age2. women 60 years3. family history of CVD,

hypertension, smoking, dyslipidemia, or albuminuria

ASA : blocking COX blocking thromboxane synthase inactivate the production thrombin X Platelet aggregation

CONGESTIVE LIVER DISEASE

History

history of consuming alcoholIVDU(-) transfusion

(-)

PE

icteric sclera

Asymmetric abdomen

Hepatomegaly: congestive liver

Supporting

SGOT 38U/L (↑), SGPT 66U/L (↑)

albumin 2.7 (↓)

total bilirubin 8.5 mg/dl(↑), direct :6.5 mg/dl(↑), indirect :

2.1 mg/dl(↑)prolonged PT (15.2/11.7

seconds)

US: hepatomegalyDiagnostic Plan:HbsAg and anti HCVManagement Plan: CHF Treatment Hepatoprotector??

CHF Patient with congestive signs

HYPONATREMIA - UTIHyponatremia 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. Ceftriaxone 3 x 1 gram.

Dilusional Hyponatremia: HF edematous state ECF vol >>

Related to DM & nephrolithiasis

Terima Kasih

THANK YOU

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