Dini Noviani Pratiwi030.08.084

MEDICAL FACULTY OF TRISAKTI UNIVERSITY

RSUD KARAWANG

Name : Mrs. TSex : FemaleAge : 59 yoAddress : Dongkal II 13/02 PedisOccupation : HousewifeReligion : MoeslimRace : SundaneseEducation : Elementary schoolMarital Status : MarriedDate of admission : 16th july 2012Taken from : Rengas Dengklok

Ward

IDENTITY

CLINICAL HISTORYCLINICAL HISTORY

CHIEF COMPLAINT : Shortness of breath since about 10 days before hospitalized.

ADDITIONAL COMPLAINT

Abdominal Pain

nausea

Vomit

Swelling in the both feet Cough

HISTORY OF PRESENT ILLNESSHISTORY OF PRESENT ILLNESS

The patient came to Emergency Unit of Karawang Hospital with complaint of shortness of breath since 10 days before hospitalized. The symptom felt worsening and appeared when she is in rush and during her normal activities such as sweeping . The symptom appeared when she lies flat on her back, and because of it she’s using 2 - 3 pillows when sleeping. She always suddenly woken up when she is sleeping because of breathlessness.

She also complained of having both feet swelling a week before admission, esp at night. The swelling getting worse from day to day. She also complaint pain in the right upper stomach . The breathlessness is not affected by cold, dust, or emotion, and no wheezing. She denied having a chest pain, fever, but suffered a bit of nausea and vomit.

She also complaining dizziness since 1 day before hospitalized. The dizziness is getting worse since the onset but getting better when she take a rest. She also complaining cough with phlegm, blood is negative.

Miction was about 7-8 times/day. Urine color was yellow. Defecation was normal.

HISTORY OF PRESENT ILLNESSHISTORY OF PRESENT ILLNESS

HISTORY OF PAST ILLNESSHISTORY OF PAST ILLNESS

- Gastritis- Hypertension since 5 Years ago

- Gastritis- Hypertension since 5 Years ago

- Diabetes Melitus- Allergy- Cardiovascular disease- Kidney disease- Asthma

- Diabetes Melitus- Allergy- Cardiovascular disease- Kidney disease- Asthma

History of Family Illness

Cardivaskular disease (-) Asthma (-) Hypertension (-) Allergy (-) DM (-)

Personal and Social History

• Smoking (-)• Alcohol (-)

• Exercise regularly (-) • Consume Ht drugs not regularly

VITAL SIGNVITAL SIGN

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

General appearance ; Moderately ill

Consciousness ; COMPOS MENTIS

PHYSICAL EXAMINATION

Head:NormocephaliAnemic conjunctiva -/-, Icteric sclera -/-Cyanotic lip (-)

Neck:Thyroid gland & lymph nodes enlargement are not palpableTrachea located in the middleJVP : (5+4) cmH2O

PE ( HEART )

I : Ictus cordis is visible at 6th ICS 3 cm lat LMCSPal : Ictus cordis is palpable at 6th ICS 3 cm lat LMCSPer : Upper R : 3rd ics, LSD

Upper L : 3rd ics, LPS Bottom R : 5th ics, LSD Bottom L : 6th ics, 3 cm lat LMCS

A : S1-2 regular murmur (+) loudest at mitral area, gallop (-)

PE ( LUNG )

Inspection : Symmetrical in static and dynamic,

intercostals retraction (-)

Palpation : Equal vocal resonance, the breath

movement symmetricPercussion : Sonor in both lungsAuscultation : Vesicular, Ronchi (+/+) at base both lungs,

Wheezing (-/-)

PE ( ABDOMEN )

Inspection: Brown skin & bloated abdomen, smiling umbilicus (-),vein dilatation (-), lesion (-), scars (-), striae (-)

Auscultation :Peristaltic sound (+) normal (3 times in 1 minute)

Palpation: Turgor normal, muscular defense (-), mass (-), hepar and lien enlargement (-), ballotement (-/-)

Percussion: Tympanic, no pain present on abdominal pecussionShifting dullness (-)

Warm acrals

Edema

EXTREMITY EXAMINATION

RESULT NORMAL

HemoglobinLeukocyteTrombocyteHtEritrosit

14.99.400

174.00046.84.68

12 – 17 g%5000 – 10000150 – 450ribu

37 – 48 %3.8 – 5.8 jt/mm2

GDSUreumCreatininSGOTSGPT

10644,71,433011

80 – 140 mg/dl10 – 45 mg/dl0.4 – 1.5 mg/dl

<40 u/l<40 u/l

LABORATORIUMLABORATORIUM

RADIOLOGYRADIOLOGY

F : Thorax PA

D : CTR > 50%- Enlargement of

Left Ventricle (LVH)- Enlargement of Right Ventricle (RVH)-Enlargement of Left Atrium (LAH)- Right costophrenicus angle is blunt

ELECTROCARDIOGRAPHY

Ax-Shortness of breath

Dispnoe on effortPNDOrtopnea

- Abdominal pain- Swelling of both feet- Nausea- Vomit- Cough- Hypertension since 5 Years ago

Ax-Shortness of breath

Dispnoe on effortPNDOrtopnea

- Abdominal pain- Swelling of both feet- Nausea- Vomit- Cough- Hypertension since 5 Years ago

Ro - CTR : >50% --> Cardiomegaly- LVH- LAH-RVH-Right CP angle blunt

Ro - CTR : >50% --> Cardiomegaly- LVH- LAH-RVH-Right CP angle blunt

PE- VT: TD : 170/100mmHg RR : 32X/M- JVP : 5+4 cmh2O- Ronchi (+/+) - Murmur (+) - Edema in both feet

PE- VT: TD : 170/100mmHg RR : 32X/M- JVP : 5+4 cmh2O- Ronchi (+/+) - Murmur (+) - Edema in both feet

RESUMERESUME

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

WORKING DIAGNOSISWORKING DIAGNOSIS

CHF NYHA II e.c HHD with Pleural Effusion DextraCHF NYHA II e.c HHD with Pleural Effusion Dextra

PROFIL LIPID

URINALYSIS

ECHOCARDIOGRAM

CARDIAC ENZYME MARKER

PROFIL LIPID

URINALYSIS

ECHOCARDIOGRAM

CARDIAC ENZYME MARKER

SUGGESTED EXAMINATIONSUGGESTED EXAMINATION

• Total bed rest• O2 2-4L/m• Low salt diet• IVFD D5% 20tpm• Lasix 2 x 1 amp• Ceftriaxone 1 x 2gr• Acran 2 x 1 amp• Ambroxol syr 3 x CI• Captopril 2x 12,5mg

• Total bed rest• O2 2-4L/m• Low salt diet• IVFD D5% 20tpm• Lasix 2 x 1 amp• Ceftriaxone 1 x 2gr• Acran 2 x 1 amp• Ambroxol syr 3 x CI• Captopril 2x 12,5mg

TREATMENT

PROGNOSIS

Bonam

Thank You