Dini Noviani Pratiwi 030.08.

084 MEDICAL FACULTY OF TRISAKTI UNIVERSITY RSUD KARAWANG

IDENTITY

Name Sex Age Address Occupation Religion Race Education Marital Status Date of admission Taken from

: Mrs. T : Female : 59 yo : Dongkal II 13/02 Pedis : Housewife : Moeslim : Sundanese : Elementary school : Married : 16th july 2012 : Rengas Dengklok Ward

CLINICAL HISTORY
CHIEF COMPLAINT : Shortness of breath since about 10 days before hospitalized. ADDITIONAL COMPLAINT
Abdominal Pain
Swelling in the both feet Cough Vomit nausea

HISTORY 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 shes 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.

HISTORY OF PRESENT ILLNESS

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 PAST ILLNESS

- Gastritis - Hypertension since 5 Years ago

- 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

PHYSICAL EXAMINATION
General appearance ; Moderately ill Consciousness ; COMPOS MENTIS

VITAL SIGN
BP: 170/100 mmHg HR: 96x/m

RR: 32x/m

T: 36,9 C

PHYSICAL EXAMINATION
Head: Normocephali Anemic conjunctiva -/-, Icteric sclera -/Cyanotic lip (-)
Neck: Thyroid gland & lymph nodes enlargement are not palpable Trachea located in the middle JVP : (5+4) cmH2O

PE ( HEART )
I Pal Per : Ictus cordis is visible at 6th ICS 3 cm lat LMCS : Ictus cordis is palpable at 6th ICS 3 cm lat LMCS : Upper R : 3rd ics, LSD Upper L : 3rd ics, LPS Bottom R : 5th ics, LSD Bottom L : 6th ics, 3 cm lat LMCS : S1-2 regular murmur (+) loudest at mitral area, gallop (-)

PE ( LUNG )
Inspection Palpation : Symmetrical in static and dynamic, intercostals retraction (-) : Equal vocal resonance, the breath movement symmetric : Sonor in both lungs : Vesicular, Ronchi (+/+) at base both lungs, Wheezing (-/-)

Percussion Auscultation

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 pecussion Shifting dullness (-)

EXTREMITY EXAMINATION
Warm acrals

Edema

LABORATORIUM
RESULT
Hemoglobin Leukocyte Trombocyte Ht Eritrosit
14.9 9.400 174.000 46.8 4.68

NORMAL
12 17 g% 5000 10000 150 450ribu 37 48 % 3.8 5.8 jt/mm2

GDS Ureum Creatinin SGOT SGPT

106 44,7 1,43 30 11

80 140 mg/dl 10 45 mg/dl 0.4 1.5 mg/dl <40 u/l <40 u/l

RADIOLOGY
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

RESUME
Ax
-Shortness of breath Dispnoe on effort PND Ortopnea - Abdominal pain - Swelling of both feet - Nausea - Vomit - Cough - Hypertension since 5 Years ago

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

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

DIFFERENTIAL DIAGNOSIS

CHF NYHA II e.c HHD with Pleural Effusion

CHF e.c Cardiomyopathy

CHF e.c MR

CAD

WORKING DIAGNOSIS

CHF NYHA II e.c HHD with Pleural Effusion Dextra

SUGGESTED EXAMINATION
PROFIL LIPID

URINALYSIS
ECHOCARDIOGRAM

CARDIAC ENZYME MARKER

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

PROGNOSIS
Bonam

Thank You