Lecturer :

Prof. DR. dr. Moch. Fathoni, Sp. JP(K), FIHA

By:
Fitrian Sufianasari (G99122048)
Name : Mrs. S.M
Age : 30 years old
Gender : Female
Religion : Moslem
Occupation : Housewife
Address : Jebres, Surakarta
Medical Record : 01224878
Hospitalized : January 15
th
2014

SHORTNESS OF BREATH
Patient has been complaining shortness of
breath, getting worse in two days before
admission to the hospital. It is triggered by
activity and not relieved by rest .
Patient slept with three pillows and more
comfortable on seat position, often awakened
at night due to dyspnea.
Ankle swelling (+) 2 days before admission.
Productive cough with white sputum (+) since 2
days before admission
Palpitation (+), chest pain (-)
This complaint occurred 3 month after she has
delivered her 2
rd
baby with sectio caesarean 6
month ago.
After the delivery, patient felt fatigue and both
of her leg were swelling. Patient also could not
do any activity after delivery because of
dyspnea.
Patient was hospitalized in RSDM 3 months ago.
Diagnosed with PPCM and given medicine:
furosemid, captopril, ISDN and spironolacton.
But patient didnt control.

History of hypertension : (-)
During the pregnancy : (-)
History of diabetes mellitus : (-)
History of asthma : (-)
History of allergy : (-)
History of heart disease : (-)


History of hypertension : (-)
History of diabetes mellitus : (-)
History of asthma : (-)
History of allergy : (-)
History of heart disease : (-)


2-3 meals a day, with rice, vegetables,
soya beans (tofu and tempe), she eats
egg and meat occasionally.
NUTRITIONAL
BEHAVIOR
Doesnt smoke. Doesnt drink alcohol. LIFE STYLE
She is an unemployment with 1 husband
and 2 children. Her husband works as a
labour. Paid using BPJS facility.
SOSIOECONOMIC
General Condition : breathlessness, Compos mentis

Vital Signs :
BP = 100/70 mmHg
HR = 120 bpm, reguler, normal intensity
RR = 28 times/minute
Temperature = 36,2C (axillar)

Nutritional status: Height 155 cm, weight 60 kg
Nutritional status = normoweight


Eyes : Pale conjunctiva (+/+),
Icteric conjunctiva (-/-)
Neck : JVP was increased R+ 5 cm,
No enlargement of lymphonode
Thorax : normochest, symmetrical,
intercostal retractions (-)

Heart :

- Inspection :
Ictus cordis was seen at SIC VI Linea Axilaris Anterior Sinistra, left and
right ventricle activity was increased

- Palpation :
Ictus cordis was palpable at SIC VI 3 cm lateral of Linea Axilaris Anterior
Sinistra, heaving (+), thrill (-)

- Percussion :
1. Upper limit of the right heart: ICS II, linea parasternalis dextra
2. Bottom right cardiac border: ICS IV, linea parasternalis dextra
3. Upper left cardiac border: ICS II, linea parasternalis sinistra
4. Lower left cardiac border: ICS VI, linea axillaris anterior sinistra
Impression: cardiac border was extended caudolaterally

- Auscultation:
1. Heart Rate: 120 bpm, regular
2. Intensity of the 1
st
and 2
nd
heart sound were normal, regular, pansystolic
murmurs (+) grade III/6 at the apex and LLSB
Lungs :
Front
Inspection : symmetric statically and
dynamically
Palpation : fumbling fremitus for right = left
at ICS V and lower
Percussion : sonor / sonor at ICS V and
lower
Auscultation : vesicular sounds (+ /+ ) at ICS V
and lower, crackles (-/-), rales (+/+) in 1/2 basal area
of the lungs


Lungs :
Back
Inspection : symmetric statically and
dynamically
Palpation : fumbling fremitus for right = left
started from VT VII
Percussion : sonor / sonor started from VT
VII
Auscultation : vesicular sounds (+ /+ ) started
from VT VII, crackles (-/-), rales (+/+) in 1/2 basal
area of the lungs

Abdominal :
Inspection : Abdomen wall was symmetric to chest wall
Auscultation : Intestinal sound (+) normal
Palpation : Tenderness (-), liver was palpable 5 cm below
arcus costae dextra
Percussion : Tympanic on all over the abdomen region

Back : kyphosis (-), lordosis (-), scoliosis (-)

Extremity :
- Upper : edema (+/+), cold acral (-/-)
- Lower : edema (+/+), cold acral (-/-)


18/4/2013

UNIT

Hb 10,6 g/dl
HCT 31 %
RBC 3,52 10
6
/l
WBC 9,8 10
3
/l
PLT 459 10
3
/l
GDS 228 mg/dL
SGOT 18 u/l
SGPT 13 u/l
Albumin 2,6 g/dl
Ureum 142 mg/dL
Creatinin 2,1 mg/dL
Natrium 140
mmol/L
Kalium 5,6
mmol/L
Chlorida 116
mmol/L
Normal P wave
PR interval 0,12 seconds
QRS complex 0,08 seconds
R-R regular, HR 130 bpm
Normal T wave
Poor R wave V1-4
CONCLUSION
LAH
Pulmonary edema with
bilateral pleural efussion

CTR is difficult to be evaluated
Apex is difficult to be evaluated
Cardiophrenicus angle is difficult to be
evaluated
Cardiac waist disappear
Costophrenic angle is blunt



Anatomic : Peripartum cardiomyopathy
Functional : CHF NYHA IV
Etiology : Cardiomyopathy
Comorbid : azotemia, hypoalbuminemia,
hyperkalemia, hyperglikemia, anemia

ICVCU
Half-sitting bedrest
O2 6 lt/mnt NRM
Infus RL 10 cc/jam
Furosemid Inj loading dose 40 mg IV
followed by 20 mg/8 hours
Morphine Inj. 20 mg titration prn
Spironolakton 25 mg 1-0-0
ISDN 3 x 5 mg
Captopril 3x12,5 mg
Fluid balance
Consult pulmonologist to manage the
bilateral pleural effusion
Echocardiography
Ad Vitam : dubia ad bonam
Ad Sanam : dubia ad bonam
Ad fungsionam : dubia ad bonam