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Morning report:
Atrial Fibrillation in Elderly
Patient with Gatroenteritis
Nuriza Karuniawan
RESOURCE PERSON:
Dr. dr. Soroy Lardo SpPD, FINASIM
DEPARTMENT OF INTERNAL MEDICINE
RS KEPRESIDENAN RSPAD GATOT SOEBROTO
AUGUST 2017
IDENTITY
Name : Mr. H
DOB/Age : February 20th 1989/ 28 years old
Religion : Moslem
Marital Status : Married
Address : Asr. Yon-23 Grup 2 Kopassus Semplak Bogor
Medical Record : 858699
Admission : July 10th 2017 01.30 AM
Ward : PU 2nd Floor
CHIEF COMPLAINT
Watery diarrhea since 4 days before hospital admission
HISTORY OF PRESENT ILLNESS
 Five days before admission to RSPAD, patient felt dizzy and muscular
aching, but fever was denied
 Four days before admission, patient felt fever, repeated at interval 2 days
(once fever once not), fever last throughout the day, followed by chills,
sweating, headache, and muscular aching and weakness. History of fever at
particular time of a day is denied, highest temperature recorded might reach
up to 39◦C
 Patient also complained feeling nauseous during meal without history of
vomiting. Decreased of appetite was denied.
 No history of cough, nor shortness of breath, normal micturition and
defecation. No abdominal pain. No nosebleed, no bleeding of gums
HISTORY OF PRESENT ILLNESS
 Patient has experienced military exercise in Merauke about 2 months.
After 1 month running, patient experienced fever and felt not so good
in his body. Then, he had sought medical assistance to RST Merauke
(July 06th, 2017), ran blood tests and was diagnosed with Malaria
Tropicana (based on his story, but the data was not brought to
Jakarta).
 He said that he was injected with Artesunat injection there with 2x60
mg doses for 2 days, and Primakuin 3 tablets single dose but he didn't
get the next dose of Artesunat injection because he already must be
evacuated to Jakarta for further treatment.
 Patient was evacuated to Jakarta in July 8th, 2017
HISTORY OF PAST ILLNESS
• Patient was already diagnosed with malaria four times before:
• 1st attack was diagnosed with Malaria Tertiana
• 2nd attack was diagnosed with Malaria Tropicana
• 3rd attack was diagnosed with Mix Tropicana-Tertiana
• 4th attack was diagnosed with Malaria Tertiana
and this time is his fifth attack of Malaria
• Three previous Malaria before were got when he was in duty about one year
in Wembi, Papua, and the last one was got in Jakarta a week after he came
back from his duty from Papua
• He has history of Tuberculosis in 2014, taking routine medication for 6
months, and had been declared cured by the physician
• He also has history of fistula anal operation in 2014
• Hypertension and type II diabetes were denied
HISTORY OF FAMILY ILLNESS AND
SOCIAL ECONOMIC STATUS
• HISTORY OF FAMILY ILLNESS
• Patient's father has a hypertension
• No diabetes, nor heart disease in his family
• No one has ever had malaria in patient's family
• SOCIAL AND ECONOMIC STATUS
• Patient is second child from 3 siblings in his family
• Patient sometimes smoke 1-2 cigarettes per day, sometimes not at all
• During exercise in Merauke, patient stated that the workload was so high so he
hadn't enough time to got a rest
• Patient works as Kopassus soldier
• Patient has been married for 1 year, now his wife is in fifth month pregnancy
and live in Malang
• Health financing with BPJS Dinas
• Intake of vitamin and another supplement are denied
• No history of chemoprophylaxis of malaria
PHYSICAL EXAMINATION
(ON PRESENTATION)
Vital Signs
BP : 132/79 mmHg
HR : 81x/min, regular, adequate
RR : 22x/min, torakal
T : 36.3◦C
BW : 66 kg
Height : 171cm
IMT : 22.7 kg/m2 (normoweight)
General Status
• Conciousness: Compos
mentis
• General condition: mildly
ill
PHYSICAL EXAMINATION
• Skin : within normal limit
• Head : normocephal, no coated tongue
• Hair : greyish black hair, hair can’t be plucked easily
• Eyes : no pale conjunctiva, no icteric sclera
• Neck : no lymph node enlargement, JVP 5-2 cmH2O
Lung
Inspection : symmetrical on insipiration and expiration
Palpation : symmetrical fremitus
Percution : sonor on both lungs
Auscultation : vesicular, no wheezing, no rales
Heart
Inspection : ictus cordis can't be located
Palpation : ictus cordis palpable on 1 finger medial to linea
midclavicularis sinistra, thrill (-), heaving (-), lifting (-)
Percussion : heart borders within normal limit
Auscultation : regular S1 S2, no murmur, no gallop
PHYSICAL EXAMINATION
Abdomen
Inspection : flat stomach
Palpation : supple, no pain on palpation, no liver or spleen
enlargement
Percussion : no shifting dullness
Auscultation : bowel sound normal
Extremities
CRT<2”, warm lower extremities, no edema, rumple leed test (-)
LABORATORY FINDING
Jenis Pemeriksaan Nilai Rujukan 09/07/2017
HEMATOLOGI
Hemoglobin 13,0-18,0 g/dL
Hematokrit 40-52 %
Eritrosit 4,3-6,0 x 106/L
Leukosit 4.800-10.800/L
Trombosit 150.000-400.000/L
MCV 80-96 fL
MCH 27-32 pg
MCHC 32-36 g/dL
KIMIA KLINIK
SGOT < 35 U/L
SGPT < 40 U/L
Ureum 20-50 mg/dL
Creatinin 0.5-1.5 mg/dL
Laboratory result (09/07/2017) in emergency admission
LABORATORY FINDING
Jenis Pemeriksaan Nilai Rujukan 09/07/2017
Glukosa Darah (Sewaktu) 70-140 mg/dL
Natrium 135-147 mmol/L
Kalium 3.5-5.0 mmol/L
Klorida 95-105 mmol/L
IMMUNOSEROLOGY
Anti Dengue IgM Negatif
Anti Dengue IgG Negatif
Jenis Pemeriksaan Nilai Rujukan 09/07/2017
Malaria
I. Plasmodium Falciparum Negatif Tidak Ditemukan
• Tropozoit
• Schizont
• Gametosit
Negatif
Negatif
Negatif
Tidak Ditemukan
Tidak Ditemukan
Tidak Ditemukan
II. Plasmodium Vivax Negatif Tidak Ditemukan
• Tropozoit
• Schizont
• Gametosit
Negatif
Negatif
Negatif
Ditemukan 12/200 Leukosit
Ditemukan 180/200 Leukosit
Ditemukan 36/200 Leukosit
III. Plasmodium Malariae Negatif Tidak Ditemukan
• Tropozoit
• Schizont
• Gametosit
Negatif
Negatif
Negatif
Tidak Ditemukan
Tidak Ditemukan
Tidak Ditemukan
IV. Plasmodium Ovale Negatif Tidak Ditemukan
• Tropozoit
• Schizont
• Gametosit
Negatif
Negatif
Negatif
Tidak Ditemukan
Tidak Ditemukan
Tidak Ditemukan
LABORATORY FINDING
RESUME
 28 year-old-male patient with chief complaint of high fever with chills
since 4 days before hospital admission. Febris with intermittent pattern,
repeated at interval 2 days, followed by headache, and muscular aching and
weakness.
 Patient already had malaria four times before, and had history of visiting
malaria endemic areas. Patient was treated as Malaria Tropicana in Merauke
and had injection Artesunat and Primaquine per oral 1x3 tab single dose.
 Physical examination revealed within normal limit. From laboratory
findings, patient is known to have Plasmodium Vivax from microscopic
examination and trombocytopenia.
PROBLEM
Acute gastroenteritis
Atrial Fibrillation Normal Ventricular Response
Problem Assessment Plan of Care Plan
Malaria
Tertiana
Based on:
History :
Fever, repeated at interval 2 days,
intermittent pattern (once fever once
not), and followed by chills, sweating,
headache, and muscular aching and
weakness
Patient was diagnosed and treated as
Malaria Tropicana in Merauke and
had injection Artesunat and
Primaquine per oral single dose.
Already had Malaria four times
before
Laboratory findings:
Plasmodium Vivax (+), Ditemukan
12/200 Leukosit (tropozoit)
Ditemukan 180/200 Leukosit
(schizont)
Ditemukan 36/200 Leukosit
(gametosit)
Plasmodium Falciparum (-)
Trombocytopenia
Target:
Clinical
improvement
Malaria cured
Diagnostic:
Thin and thick blood film for
evaluate therapy post treatment
Therapy :
- IVFD NaCl 0.9% 500 cc/8
hour
- Paracetamol 3x500mg
- DHP 1x4 tab (3 days)
- Primakuin 1x1 tab (14 days)
- Ranitidine inj. 2x1 amp
- Antacida syr 3xC1
- Domperidone 3x1 tab
Education :
─ Increase endurance by
eating lots of vegetables,
fruits, drink a lot of water,
and have enough time to get
rest
─ Take routine and regular
medication
─ Use mosquito net when
sleep
Acute Gastroenteritis
Etiology
Pathogenesis
Management
Atrial Fibrillation
• Definition
Atrial fibrilitation with gea nuriza
Atrial fibrilitation with gea nuriza
Atrial fibrilitation with gea nuriza
Atrial fibrilitation with gea nuriza
Atrial fibrilitation with gea nuriza
Atrial fibrilitation with gea nuriza
Atrial fibrilitation with gea nuriza
Atrial fibrilitation with gea nuriza
Atrial fibrilitation with gea nuriza
Management : An Evidence-based
Approach
Acute Gastroenteritis
• Evaluate hydration status  rehydration
• Empiric Antibiotic
• Probiotic
• Evaluate electrolyte disturbance
Atrial fibrilitation with gea nuriza
Management : An Evidence-based
Approach
Atrial Fibrillation
• Evaluate hemodynamic status  stable
hemodynamic
• Cardiovascular Risk Reduction
• Stroke Prevention
Atrial fibrilitation with gea nuriza
Atrial fibrilitation with gea nuriza
Atrial fibrilitation with gea nuriza
Management : An Evidence-based
Approach
Atrial Fibrillation
• Evaluate hemodynamic status  stable
hemodynamic
• Cardiovascular Risk Reduction
• Stroke Prevention
• Rate Control Therapy
Rate Control Therapy in AF
AF in elderly patients
• Cardiovascular risk reduction is more effective in
elderly than in younger patients
• Age is stronger predictor for stroke in AF
• Elderly patient is at higher risk of stroke more
likely to benefit from OAC than younger
• More comorbid (anemia, CKD, DM,
hypertension), more likely to develop
complication of AF treatment, esp bleeding the
choice and adjusting dosage are reasonable
approach
Digoxin for Rate Control Therapy
PROGNOSIS
• Ad vitam : Dubia ad Bonam
• Ad functionam : Bonam
• Ad sanationam : Dubia ad bonam
Thank You

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Atrial fibrilitation with gea nuriza

  • 1. Morning report: Atrial Fibrillation in Elderly Patient with Gatroenteritis Nuriza Karuniawan RESOURCE PERSON: Dr. dr. Soroy Lardo SpPD, FINASIM DEPARTMENT OF INTERNAL MEDICINE RS KEPRESIDENAN RSPAD GATOT SOEBROTO AUGUST 2017
  • 2. IDENTITY Name : Mr. H DOB/Age : February 20th 1989/ 28 years old Religion : Moslem Marital Status : Married Address : Asr. Yon-23 Grup 2 Kopassus Semplak Bogor Medical Record : 858699 Admission : July 10th 2017 01.30 AM Ward : PU 2nd Floor
  • 3. CHIEF COMPLAINT Watery diarrhea since 4 days before hospital admission
  • 4. HISTORY OF PRESENT ILLNESS  Five days before admission to RSPAD, patient felt dizzy and muscular aching, but fever was denied  Four days before admission, patient felt fever, repeated at interval 2 days (once fever once not), fever last throughout the day, followed by chills, sweating, headache, and muscular aching and weakness. History of fever at particular time of a day is denied, highest temperature recorded might reach up to 39◦C  Patient also complained feeling nauseous during meal without history of vomiting. Decreased of appetite was denied.  No history of cough, nor shortness of breath, normal micturition and defecation. No abdominal pain. No nosebleed, no bleeding of gums
  • 5. HISTORY OF PRESENT ILLNESS  Patient has experienced military exercise in Merauke about 2 months. After 1 month running, patient experienced fever and felt not so good in his body. Then, he had sought medical assistance to RST Merauke (July 06th, 2017), ran blood tests and was diagnosed with Malaria Tropicana (based on his story, but the data was not brought to Jakarta).  He said that he was injected with Artesunat injection there with 2x60 mg doses for 2 days, and Primakuin 3 tablets single dose but he didn't get the next dose of Artesunat injection because he already must be evacuated to Jakarta for further treatment.  Patient was evacuated to Jakarta in July 8th, 2017
  • 6. HISTORY OF PAST ILLNESS • Patient was already diagnosed with malaria four times before: • 1st attack was diagnosed with Malaria Tertiana • 2nd attack was diagnosed with Malaria Tropicana • 3rd attack was diagnosed with Mix Tropicana-Tertiana • 4th attack was diagnosed with Malaria Tertiana and this time is his fifth attack of Malaria • Three previous Malaria before were got when he was in duty about one year in Wembi, Papua, and the last one was got in Jakarta a week after he came back from his duty from Papua • He has history of Tuberculosis in 2014, taking routine medication for 6 months, and had been declared cured by the physician • He also has history of fistula anal operation in 2014 • Hypertension and type II diabetes were denied
  • 7. HISTORY OF FAMILY ILLNESS AND SOCIAL ECONOMIC STATUS • HISTORY OF FAMILY ILLNESS • Patient's father has a hypertension • No diabetes, nor heart disease in his family • No one has ever had malaria in patient's family • SOCIAL AND ECONOMIC STATUS • Patient is second child from 3 siblings in his family • Patient sometimes smoke 1-2 cigarettes per day, sometimes not at all • During exercise in Merauke, patient stated that the workload was so high so he hadn't enough time to got a rest • Patient works as Kopassus soldier • Patient has been married for 1 year, now his wife is in fifth month pregnancy and live in Malang • Health financing with BPJS Dinas • Intake of vitamin and another supplement are denied • No history of chemoprophylaxis of malaria
  • 8. PHYSICAL EXAMINATION (ON PRESENTATION) Vital Signs BP : 132/79 mmHg HR : 81x/min, regular, adequate RR : 22x/min, torakal T : 36.3◦C BW : 66 kg Height : 171cm IMT : 22.7 kg/m2 (normoweight) General Status • Conciousness: Compos mentis • General condition: mildly ill
  • 9. PHYSICAL EXAMINATION • Skin : within normal limit • Head : normocephal, no coated tongue • Hair : greyish black hair, hair can’t be plucked easily • Eyes : no pale conjunctiva, no icteric sclera • Neck : no lymph node enlargement, JVP 5-2 cmH2O Lung Inspection : symmetrical on insipiration and expiration Palpation : symmetrical fremitus Percution : sonor on both lungs Auscultation : vesicular, no wheezing, no rales Heart Inspection : ictus cordis can't be located Palpation : ictus cordis palpable on 1 finger medial to linea midclavicularis sinistra, thrill (-), heaving (-), lifting (-) Percussion : heart borders within normal limit Auscultation : regular S1 S2, no murmur, no gallop
  • 10. PHYSICAL EXAMINATION Abdomen Inspection : flat stomach Palpation : supple, no pain on palpation, no liver or spleen enlargement Percussion : no shifting dullness Auscultation : bowel sound normal Extremities CRT<2”, warm lower extremities, no edema, rumple leed test (-)
  • 11. LABORATORY FINDING Jenis Pemeriksaan Nilai Rujukan 09/07/2017 HEMATOLOGI Hemoglobin 13,0-18,0 g/dL Hematokrit 40-52 % Eritrosit 4,3-6,0 x 106/L Leukosit 4.800-10.800/L Trombosit 150.000-400.000/L MCV 80-96 fL MCH 27-32 pg MCHC 32-36 g/dL KIMIA KLINIK SGOT < 35 U/L SGPT < 40 U/L Ureum 20-50 mg/dL Creatinin 0.5-1.5 mg/dL Laboratory result (09/07/2017) in emergency admission
  • 12. LABORATORY FINDING Jenis Pemeriksaan Nilai Rujukan 09/07/2017 Glukosa Darah (Sewaktu) 70-140 mg/dL Natrium 135-147 mmol/L Kalium 3.5-5.0 mmol/L Klorida 95-105 mmol/L IMMUNOSEROLOGY Anti Dengue IgM Negatif Anti Dengue IgG Negatif
  • 13. Jenis Pemeriksaan Nilai Rujukan 09/07/2017 Malaria I. Plasmodium Falciparum Negatif Tidak Ditemukan • Tropozoit • Schizont • Gametosit Negatif Negatif Negatif Tidak Ditemukan Tidak Ditemukan Tidak Ditemukan II. Plasmodium Vivax Negatif Tidak Ditemukan • Tropozoit • Schizont • Gametosit Negatif Negatif Negatif Ditemukan 12/200 Leukosit Ditemukan 180/200 Leukosit Ditemukan 36/200 Leukosit III. Plasmodium Malariae Negatif Tidak Ditemukan • Tropozoit • Schizont • Gametosit Negatif Negatif Negatif Tidak Ditemukan Tidak Ditemukan Tidak Ditemukan IV. Plasmodium Ovale Negatif Tidak Ditemukan • Tropozoit • Schizont • Gametosit Negatif Negatif Negatif Tidak Ditemukan Tidak Ditemukan Tidak Ditemukan LABORATORY FINDING
  • 14. RESUME  28 year-old-male patient with chief complaint of high fever with chills since 4 days before hospital admission. Febris with intermittent pattern, repeated at interval 2 days, followed by headache, and muscular aching and weakness.  Patient already had malaria four times before, and had history of visiting malaria endemic areas. Patient was treated as Malaria Tropicana in Merauke and had injection Artesunat and Primaquine per oral 1x3 tab single dose.  Physical examination revealed within normal limit. From laboratory findings, patient is known to have Plasmodium Vivax from microscopic examination and trombocytopenia.
  • 16. Problem Assessment Plan of Care Plan Malaria Tertiana Based on: History : Fever, repeated at interval 2 days, intermittent pattern (once fever once not), and followed by chills, sweating, headache, and muscular aching and weakness Patient was diagnosed and treated as Malaria Tropicana in Merauke and had injection Artesunat and Primaquine per oral single dose. Already had Malaria four times before Laboratory findings: Plasmodium Vivax (+), Ditemukan 12/200 Leukosit (tropozoit) Ditemukan 180/200 Leukosit (schizont) Ditemukan 36/200 Leukosit (gametosit) Plasmodium Falciparum (-) Trombocytopenia Target: Clinical improvement Malaria cured Diagnostic: Thin and thick blood film for evaluate therapy post treatment Therapy : - IVFD NaCl 0.9% 500 cc/8 hour - Paracetamol 3x500mg - DHP 1x4 tab (3 days) - Primakuin 1x1 tab (14 days) - Ranitidine inj. 2x1 amp - Antacida syr 3xC1 - Domperidone 3x1 tab Education : ─ Increase endurance by eating lots of vegetables, fruits, drink a lot of water, and have enough time to get rest ─ Take routine and regular medication ─ Use mosquito net when sleep
  • 31. Management : An Evidence-based Approach Acute Gastroenteritis • Evaluate hydration status  rehydration • Empiric Antibiotic • Probiotic • Evaluate electrolyte disturbance
  • 33. Management : An Evidence-based Approach Atrial Fibrillation • Evaluate hemodynamic status  stable hemodynamic • Cardiovascular Risk Reduction • Stroke Prevention
  • 37. Management : An Evidence-based Approach Atrial Fibrillation • Evaluate hemodynamic status  stable hemodynamic • Cardiovascular Risk Reduction • Stroke Prevention • Rate Control Therapy
  • 39. AF in elderly patients • Cardiovascular risk reduction is more effective in elderly than in younger patients • Age is stronger predictor for stroke in AF • Elderly patient is at higher risk of stroke more likely to benefit from OAC than younger • More comorbid (anemia, CKD, DM, hypertension), more likely to develop complication of AF treatment, esp bleeding the choice and adjusting dosage are reasonable approach
  • 40. Digoxin for Rate Control Therapy
  • 41. PROGNOSIS • Ad vitam : Dubia ad Bonam • Ad functionam : Bonam • Ad sanationam : Dubia ad bonam

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