Professional Documents
Culture Documents
Patient Identity
Name
: Mrs. D
Age
: 74 years old
Gender
: female
Religion
: moslem
Occupation
: housewife
Address
: Grogol-Sukoharjo
Medical Record : 01177525
Hospitalized
: February 10th2013
CHIEF
COMPLAINT
Shortness
of breath
Historyof
ofPresent
Present illness
illness
History
Approximately a week before hospitalized,
patient felt the shortness of breath. It appeared
on activity and decreased by rest. Cold sweating
(+), awakened at night because of breathless
(+), breathless caused by changing position (-),
fainting (-), bloody coughing (-), easily tired (-).
About 3 Months ago patient complained a chest
pain, but she didnt go to the hospital, because
the pain relieved it self. Pain at left shoulder (+),
cough (+) Nausea (-), Vomitting (-)
History
History
History
History
History
History
History
of
of
of
of
of
of
of
heart disease
:
hypertension
:
stroke
: (-)
diabetes mellitus
hospitalization :
Asthma
: (-)
allergy
: (-)
(-)
(-)
: (-)
(-)
EATING BEHAVIOR
LIFE STYLE
SOSIOECONOMIC
PHYSICAL EXAMINATION
General Condition: Compos Mentis,
moderate illness
Vital Signs:
BP = 100/70 mmHg
HR = 90 bpm, reguler, normal intensity
RR = 20 times/minute
Temperature = 36,2C (axillar)
Nutritional status = normoweight
Heart :
- Inspection : Ictus cordis wasnt seen
- Palpation : Ictus cordis wast palpable
- Percussion :
1. Upper limit of the right heart: SIC II, linea parasternalis
dextra
2. Bottom right cardiac border: SIC IV, linea parasternalis
dextra
3. Upper left cardiac border: SIC II, linea parasternalis
sinistra
4. Lower left cardiac border: SIC V, 2 cm to the lateral side
of the linea mid clavicula sinistra
Impression: cardiac border wasnt extend
- Auscultation:
1. Heart Rate: 90 x/ min, regular
2. Intensity of the Heart sound I-II are normal, regular,
murmurs (-), Gallop (-)
Lungs :
Front
Inspection
: static and dynamic symmetric
Palpation
: fumbling fremitus for right = left
Percussion
: sonor/ sonor
Auscultation
: Basic vesicular sounds (+/+),
Fine crackles (+/+), rales (+/+), wheezing (-/-)
Back
Inspection
: static and dynamic symmetric
Palpation
: fumbling fremitus for right = left
Percussion
: sonor / sonor
Auscultation: basic vesicular sound (+/+), fine
crackles (+/+) in, rales crackles (+/+) lung fields,
wheezing (-/-)
Abdominal :
- Inspection : abdominal wall = chest wall
- Auscultation : bowel peristaltic (+) normal
- Percussion : tympanic
- Palpation : outgoing, tenderness (-), liver and
spleen not palpable
Back : Kyphosis (-), lordosis (-), scoliosis (-)
Extremity :
- Above : pitting edema (-/-), cold acral (-/-),
wound (-/-), clubbing finger (-/-), spoon nail (-/-)
- Under : pitting edema (-/-), cold acral (-/-),
wound (-/-), clubbing finger (-/-), spoon nail (-/-)
10/2/2013
L
A
B
O
R
A
T
O
R
Y
F
I
N
D
I
N
G
15/2/2013
UNIT
Hb
9,9
g/dl
HCT
32
RBC
3,56
106/l
WBC
9,1
103/l
PLT
299
103 /l
GDS
118
mg/dL
Ureum
53
mg/dL
Creatinin
1,8
mg/dL
130
mmol/L
Kalium
2,8
mmol/L
Chlorida
91
mmol/L
Natrium
Ca Ion
mmol/L
CKMB
ng/l
Troponin
ug/l
L
A
B
O
R
A
T
O
R
Y
10/02/201
3
F
I
N
D
I
N
G
15/2/201
3
UNIT
SGOT
190
u/l
SGPT
91
u/l
Triglyserid
83
mg/dl
Total
cholesterol
116
mg/dl
LDL
Cholesterol
58
mg/dl
E
C
G
Tgl
25/5/2011
E
C
G
E
C
G
E
C
G
E
C
G
E
C
G
CONCLUSIO
N:
- AF rapid ventricular
response HR 160x/mnt
- Poor R wave progression
- Biventricular enlargement
C
H
E
S
T
XRAY
C
H
E
S
T
XRAY
Simetric
Bronchovascular system is normal
Perihiller haze in both lungs
Costophrenic angle is blunt
CTR >50 %
Calsification of aortic knob
CONCLUSION
Cardiomegaly with aorto
schlerosis
Oedem pulmo
Bilateral efussion of pleura
C
H
E
S
T
XRAY
DIAGNOSIS
Anatomic : anteroseptal
OMI
Functional :
Decompensated cordis
NYHA IV
Etiology : coronary heart
disease
Risk Factors : Age,
Menopause
T
R
E
A
T
M
E
N
T
Bed rest
O2 3lt/mnt
Infus RL 10 dpm
Furosemid Inj 20 mg/8 hours
Ranitidin Inj. 50 mg/12 hours
Spironolakton 25 mg 1-0-0
ISDN 3 x 5 mg
Captopril 3x12,5 mg
Simvastatin 20 mg 0-0-1
Alprazolam 0,5 mg 0-0-1
Aspilet 80 mg 0-1-0
Ambroxol 3x30
Allopurinol 100mg 0-0-1
KSR 3x1
P
L
A
N
PROGNOSIS
Ad Vitam : dubia ad bonam
Ad Sanam : dubia ad malam
Ad funsionam : dubia ad malam
THANK YOU
YOU
THANK
FOR YOUR
YOUR
FOR
ATTENTION
ATTENTION