Review OSCE Kardio - LBZ [PDF]

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Keterampilan    



Pemeriksaan fisik Pemeriksaan fisik diagnostik Pemeriksaan diagnostik Resusitasi



 Penyakit kardiovaskuler          



Stable angina Sindrom koroner akut Radang dinding jantung Gagal jantung PJR dan penyakit katup Aritmia Cardiac arrest Penyakit Jantung Bawaan Hipertensi Vaskuler



 Latihan EKG



• • • • • • • •



Status generalis Status lokalis EKG Stable angina Sindrom koroner akut Gagal jantung Aritmia Hipertensi



KELUHAN UTAMA



INDEKS Part 1: Pemeriksaan fisik (SKDI based) Part 2: Penyakit kardiovaskular (SKDI based) 1. Stable angina 2. SKA 3. Gagal jantung 4. Aritmia 5. Cardiac arrest Part 3: Review EKG



KETERAMPILAN



Part 1



A



B



C



D



A. PEMERIKSAAN FISIK 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.



Inspeksi dada 4A Palpasi denyut apeks jantung 4A Palpasi arteri karotis 4A Perkusi ukuran jantung 4A Auskultasi jantung 4A Pengukuran tekanan darah 4A Pengukuran JVP 4A Palpasi denyut arteri ekstremitas 4A Penilaian CRT 4A Deteksi bruits 4A



STATUS GENERALIS Regio



Temuan Nadi



Vital sign



Kepala/Leher



Thorax Paru Abdomen Ekstremitas



Normal 60-100 bpm Reguler Kuat angkat



Patologi Bradi 100 bpm AF  irreguler Syok  lemah



Respiratory rate



16-20 x/menit Tanpa retraksi



Gagal jantung  dyspneu



Tekanan darah



Sistolik: 35 mm  Pergeseran aksis CCW



 RVH:  R dominan di V1 (R/S ratio > 1).  S dominan di V5/V6 (R/S ratio < 1).  Pergeseran aksis CW



 Echocardiography penurunan fraksi ejeksi



     



Lasix 20-40mg iv (max 600mg/hari) Morfin 1-5mg iv bila perlu Nitrat 5-10mg SL Oksigen nasal prong 2-4 lpm Posisi duduk RUJUK



• Kronis  ACEi/ARB  Tab. Captopril 3x25 mg



 Beta Bloker  Tab. Bisoprolol 1x1,25 mg titrasi



 Diuretik  Tab. HCT 1x25 mg



1 Gagal Jantung EDUKASI • Diagnosis: jantung tidak dapat memompa darah secara optimal • Faktor resiko: – – – –



HT DM Dislipidemia Yg tidak terkontrol



• Komplikasi: henti jantung, gangguan keseimbangan elektrolit. • Planning: – Restriksi cairan (1-1,5 L/hr) – Diet rendah garam – Saat akut tirah baring, saat stabil light exercise – Rujuk SpJP – Rawat jalan



• Prognosis: dubia



Plain Chest Radiography LVH



Cara Baca • • • • •



Foto Polos PA Regio Thorax Identitas Pasien Layak baca Trakea di tengah Jantung  CTR >50%  Pergeseran batas jantung kanan  Pergeseran batas jantung kiri dengan apex tertanam



 Paru  Batwings appearance  Kerley B lines



 Diafragma normal  Costa normal  Soft tissue normal



Batwing’s appearance



Plain Chest Radiography RVH



Cara Baca • • • • •



Foto Polos PA Regio Thorax Identitas Pasien Layak baca Trakea di tengah Jantung  CTR >50%  Pergeseran batas jantung kanan  Pergeseran batas jantung kiri dengan apex rounded



 Paru  Peningkatan corak vaskuler paru



 Diafragma normal  Costa normal  Soft tissue normal



Plain Chest Radiography Congestive Heart Failure



Cara Baca • • • • •



Foto Polos PA Regio Thorax Identitas Pasien Layak baca Trakea di tengah Jantung  CTR >50%  Pergeseran batas jantung kanan  Pergeseran batas jantung kiri dengan apex tertanam



 Paru  Batwings appearance  Kerley B lines



 Diafragma normal  Costa normal  Soft tissue normal



• • • •



Layak baca Irama sinus Rate 300/kotak sedang Aksis  Frontal: normal  Horizontal: normal



• S V1 + R V5 > 35 mm



• • • •



Layak baca Irama sinus Rate 300/kotak sedang Aksis  Frontal: normal  Horizontal: normal



• R dominan di V1 • S dominan di V5/V6 • P pulmonal di lead II



• • • •



Layak baca Irama sinus Rate 300/kotak sedang Aksis  Frontal: defleksi kiri (I+ aVF-)  Horizontal: rotasi CW(V5-V6)



• • • •



P mitrale di lead II  AAKi PVC LBBB RBBB AV Blok derajat 1



3 Penyakit Jantung Rematik ANAMNESIS • Identitas wanita muda • KU sesak • Keluhan lain berdebar, pingsan, limitasi aktivitas • RPD sering sakit tenggorokan saat kecil/bertahun-tahun lalu • RPK tak terkait



PEMERIKSAAN FISIK • • •



KU: bisa lemah GCS: bisa menurun VS  Taki/bradi/aritmia  Dyspnea  TD bisa tinggi



 St. Generalis  K/L: peningkatan JVP  Abdomen: asites, hepatomegali  Ekstremitas: aPDB, edema



 St. Lokalis Thorax     



Murmur diastolik di apex Pelebaran batas jantung Gallop S3 (derap kuda) Ronkhi Pulsus deficit



Murmur Sistolik • ASMI    



Grade • I-VI



Aorta Stenosis Mitral Insufisiensi Pulmonal stenosis Trikuspid insufisiensi



Diastolik • Selain ASMI    



Aorta regurgitasi Mitral stenosis Pulmonal regurgitasi Trikuspid stenosis



Sifat • High pitched (crescendo) • Low pitched (decrescendo)



3 Penyakit Jantung Rematik PEMERIKSAAN PENUNJANG • EKG sesuai klinis  CXR sesuai klinis  Echocardigraphy mitral stenosis dapat disertai trikuspid regurgitasi



TERAPI • Valvuloplasty • Stabilkan KU • Rujuk



3 Penyakit Jantung Rematik EDUKASI • Diagnosis: gangguan penutupan katup jantung • Faktor resiko: – Sering sakit tenggorokan



• Komplikasi: gagal jantung, henti jantung. • Planning: rujuk. • Prognosis: dubia



BERDEBAR-DEBAR



D i s r it m i a



Disritmia Anamnesis • Keluhan bisa berupa:       



Palpitasi Sesak nafas Mudah lelah Nyeri/rasa tidak nyaman di dada Pusing Sinkop Berkeringat



 Faktor resiko     



PJK Kelainan jantung lain Gangguan cemas dan stress Gangguan elektrolit Hipertiroid



Pemeriksaan Fisik • Takikardi (>100 bpm) • What to do?



Assess stability Tidak stabil bila 1. Penurunan kesadaran 2. Hipotensi 3. Nyeri dada 4. Tanda gagal jantung 5. Gangguan perfusi



Disritmia Penunjang • EKG – SVT: kompleks QRS sempit, frekuensi >150 bpm – VT: kompleks QRS lebar, frekuensi >150 bpm



Terapi • Tidak stabil – Rujuk dengan terpasang infus – RJPO – Oksigen mask 10-15 lpm



• Stabil – Cari penyebab – Oksigen mask 4-6 lpm – Rujuk



Aritmia stabil Atrial fibrilasi klinis stabil Atrial flutter



Medikamentosa Amiodaron 1x600mg



Medikamentosa



SVT klinis stabil



Vagal manuver, Kardioversi elektif



Premature Ventricular Complex /Ventricular Extrasystole tunggal



Cari penyebab, medikamentosa, kardioversi elektif, ablasi



Aritmia tidak stabil



Pulseless VT



Defibrilasi (Bifasik: 200 J, mono 360 J)



VF



Defibrilasi (Bifasik: 200 J, mono 360 J)



Asystole



PEA AF, SVT, PVC lain klinis tidak stabil



RJPO RJPO Kardioversi



Kardioversi mulai 100 J



CARDIAC ARRHYTMIAS



1 . Cepat 2. Lambat 3. Ireguler



CEPAT – ATAS (QRS SEMPIT)  Sinus takikardi



 SV T



CEPAT – ATAS (QRS SEMPIT)



CEPAT – BAWAH (QRS LEBAR)



Bundle Branch Block Left: R bertakik di lead I dan V6 Right: rSR’ di lead V1



VT



VF



LAMBAT  Sinus bradikardi



 Asistole



AV BLOCK 3 degrees of separations First,



P dan QRS menjauh, tapi tetep pacaran







Second,



P dan QRS semakin jauh, sempet ga kontakan, tp balikan



Per tamanya deket, agak menjauh, menjauh banget, eh hilang...



Kedua ga ada angin ga ada ujan tiba -tiba hilang...



Third,



P dan QRS menjalani hidup mereka masing -masing...



AV BLOCK  AV Block derajat I  PR memanjang tanpa ada QRS hilang



 AV Block derajat III/Total AV Block  P dan QRS jalan sendiri



IREGULER  AV Block derajat II Mobitz 1  lambat laun hilang



 AV Block derajat II Mobitz 2  tiba-tiba hilang



LAIN-LAIN



Cardiac arrest ToF/PJB Lain



1 ToF ANAMNESIS • Identitas bayi, anak • KU Sesak/Biru • Keluhan lain clubbing finger, jongkok saat kecapaian



• Tanda gagal jantung



PEMERIKSAAN FISIK • KU, GCS, VS cenderung tidak stabil • St. Generalis: JVP, asites, edema, akral, CRT, clubbing fingers • St. Lokalis thorax: – – – –



RVH: pelebaran batas jantung VSD: pansystolic murmur Stenosis pulmonal: syst murm Overriding aorta



1 ToF PEMERIKSAAN PENUNJANG • EKG  RVH



 CXR  Bootshaped heart



TERAPI • Knee chest position • Oksigenasi • Morfin bila perlu • Rujuk



1 ToF EDUKASI • Diagnosis: penyakit jantung bawaan



• Komplikasi: gagal jantung, henti kematian. • Planning: Terapi farmakologis, rujuk, rawat jalan. • Prognosis: dubia



Plain Chest Radiography ToF



Cara Baca • • • • •



Foto Polos PA Regio Thorax Identitas Pasien Layak baca Trakea di tengah Jantung    



CTR 45 thn/perempuan menopause, status ekonomi tinggi



• Keluhan – – – – – –



Tanpa keluhan Keluhan serebral Keluhan mata Keluhan jantung Keluhan ginjal Keluhan perifer



• RPD HT, Dislipidemia, Diabetes • •



Melitus, Penyakit jantung, Riwayat pengobatan RPK orang tua atau saudara menderita darah tinggi RPSos aktivitas rendah, merokok, Alkohol, Diet tinggi lemak jenuh, kolesterol, kalori, Kepribadian tipe A



PEMERIKSAAN FISIK Dx



TD



Keterangan



HT stage I



≥140/90



120 ms  Dominant S wave in V1  Broad monophasic R wave in lateral leads (I, aVL, V5-V6)  Absence of Q waves in lateral leads (I, V5-V6; small Q waves are still allowed in aVL)  Prolonged R wave peak time > 60ms in left precordial leads (V5-6) Ribet? Iya Mau gampang? Liat di V1, kalo defleksi QRS terakhir negatif, berarti LBBB



4



STEMI INFERIOR ST elevation in leads II, III and aVF Progressive development of Q waves in II, III and aVF Reciprocal ST depression in aVL (± lead I) Which artery?  80% RCA, 18% LCx  Occasionally LAD. This produces the unusual pattern of concomitant inferior and anterior ST elevation.



5



SVT  Regular tachycardia ~140-280 bpm.  QRS complexes usually narrow (< 120 ms) unless pre-existing bundle branch block, accessory pathway, or rate related aberrant conduction.  ST-segment depression may be seen with or without underlying coronary artery disease.  QRS alternans – phasic variation in QRS amplitude associated with AVNRT and AVRT, distinguished from electrical alternans by a normal QRS amplitude.  P waves if visible exhibit retrograde conduction with P-wave inversion in leads II, III, aVF.  P waves may be buried in the QRS complex , visible after the QRS complex, or very rarely visible before the QRS complex.



6



AV BLOCK: 2ND DEGREE, MOBITZ I (WENCKEBACH PHENOMENON) + STEMI INFERIOR Progressive prolongation of the PR interval culminating in a non-conducted P wave The PR interval is longest immediately before the dropped beat The PR interval is shortest immediately after the dropped beat AV block 2 nd degree mobitz I : Intinya, PR memanjang dulu, trus QRS hilang



7



VF Chaotic irregular deflections of varying amplitude No identifiable P waves, QRS complexes, or T waves Rate 150 to 500 per minute



8



VES / PVC



9



LVH The most commonly used are the SokolovLyon criteria : S in V1 + tallest R in V5-V6 > 35 mm ST segment depression and T wave inversion in the left-sided leads: AKA the left ventricular ‘strain’ pattern



10



PEA / ASYSTOLE  So obvious.



11



ATRIAL FIBRILASI Irregularly irregular rhythm. No P waves. Absence of an isoelectric baseline. Variable ventricular rate. QRS complexes usually < 120 ms unless pre-existing bundle branch block, accessory pathway, or rate related aberrant conduction.  Fibrillatory waves may be present and can be either fine (amplitude < 0.5mm) or coarse (amplitude >0.5mm).  Fibrillatory waves may mimic P waves leading to misdiagnosis     



12



PVC Broad QRS complex (≥ 120 ms) with abnormal morphology. Premature — i.e. occurs earlier than would be expected for the next sinus impulse. Discordant ST segment and T wave changes. Usually followed by a full compensatory pause. Retrograde capture of the atria may or may not occur



13



VT  Rapid hear t rate (> 100 b p m).  Broad QRS complexes (> 1 20 ms).  A b s e n c e o f t y p i c al R B B B o r L B B B m o r p h o l o g y.  E x t r em e a x i s d ev i a t i o n ( ― n o r t h we s t a x i s ‖ ) — Q R S i s p o s i t i ve i n a V R a n d n e g a t i ve i n I + a V F.  AV d i s s o c i a t io n ( P a n d Q R S c o m p lexe s a t d i f fe r e n t r a te s ) .  C a p t ur e b e a t s — o c c ur w h e n t h e s i n o a t r i al n o d e t r a n s i e n t l y ‗ c a p t ur e s ‘ t h e v e n t r i c le s , i n t h e m i d s t o f AV d i s s o c ia t i o n , to p r o d uc e a Q R S c o m p l ex o f n o r m a l duration.  Fu s i o n b e a t s — o c c ur w h e n a s i n u s a n d v e n t r i c ula r b e a t c o i n c id e to p r o d uce a hy b r i d c o m p l ex o f i n te r m e d i a te m o rp h o l o g y.  Po s i t iv e o r n e g a t i ve c o n c o r d a n c e t h r o ug h o ut t h e c h e s t l e a d s , i . e . l e a d s V 1 - 6 s h o w e n t i r el y p o s i t iv e ( R ) o r e n t i r el y n e g a t i v e ( Q S ) c o m p lexe s , w i t h n o R S c o m p l exe s seen.  B r u g a d a ‘ s s i g n – T h e d i s t a n c e f r o m t h e o n s et o f t h e Q R S c o m p l ex to t h e n a d i r o f t h e S - w ave i s > 1 0 0 m s .  J o s e p h s o n ‘ s s i g n – N o t c h i n g n e a r t h e n a d i r o f t h e S - w ave .



 RSR‘ complexes with a taller ―lef t rabbit ear‖. This is the most specific finding in favour of V T. This is in contrast to RBBB, where the right rabbit ear is taller.