LISA ATRIA ARIYANI
30101306977
Advisor :
dr. H. M. SAUGI ABDUH, Sp.PD., KKV, FINASIM
Name : Mr. M
Age : 47 years
Gender : Male
Religion : Moslem
Job : swasta
Address : Ngemplak Selatan RT 01/RW 05, Rembang
MR number : 1329067
Room : Baitul Izzah 1 409.2
Entry date : 28 September 2017
Date out : 6 October 2017
Dyspneu
Chest Pain
Patient came to poli clinic Sultan Agung Islamic Hospital
complained about his abnormal breathing (dyspneu) and
chest pain from 1 month ago. He feels dsypneu when
activity and feels better when take a rest. Chest pain feels
at left chest and ussualy appear at night.
HISTORY OF PREVIOUS ILLNESS
DM history (-)
Hypertension history (-) Gastritis (+)
SOSIO-ECONOMIC HISTORY :
DM History (-) Hospital cost certified by JKN NON PBI
Asthma history (-)
Asthma history (-)
Alergy history (-)
Alergy history (-)
Smoking (-)
Alcohol (-)
Smoking (-)
FAMILYS HISTORY OF DISEASE
Tranfution history (-)
Hypertension history (-)
DM history (-)
Asthma history (-)
Alergy history (-)
Main Complains : dyspneu and chest pain
Onset : 1 month ago
Location : chest
Quality and Quantity : patient feel dsypneu when activity and chest pain likes a
stab.
Chronology : He complain that 1 months ago, he feel hard to breath when
he working and feels better when take a rest
Modification factor : he felt better when break the activity and sit back relax
Comorbid complains : fatigue
General : dyspneu
Skin : itching (-), jaundice (-), pale (-), slick (-)
Head : headache (-)
Eyes : blurred vision (-), red eyes (-), icteric sclera (-/-)
Ears : hearing loss (-), ring (-), discharge (-)
Nose : nosebleed (-), discharge (-)
Mouth : cyanosis (-), thrush (-), bleeding gums (-)
Throat : pain swallow(-), hoarseness (-), difficult in swallowing (-)
Neck : enlargement of the gland (-)
Chest : cough (-), sputum (-), blood (-)
Cardiac : chest pain (+), palpitations (-)
Digestive : abdominal pain (-), nausea (-), vomiting (-)
Musculoskeletal : weak (-), rigid (-), back pain (-)
Extremity : oedem extremity (-)
BMI (Body Mass Indeks)
Weight : 56 kg BMI = 56 : 2,4 = 23,30
High : 155 cm
Interpretation : Normo Weight
Awareness : Fully Aware / Compos Mentis
Vital Sign :
Blood Pressure : 115/80 mmHg
Heart rate : 86 x/minute
Breath Frequency : 24 x/minute
Temp : 36,8 oC
Interpretation : Normal
INSPEKSI ANTERIOR POSTERIOR
Static RR : 28x/min, Hyper pigment (-), spider nevi RR : 28x/min, Hyper pigment
(-), atrophy Pectoral Muscle (-), Hemithoraks (-),spider nevi (-), Hemithoraks D=S,
D=S, ICS Normal, Diameter AP < LL ICS Normal, Diameter AP < LL
Dynamic Up and down of hemitoraks D=S, Up and down of hemitoraks D=S,
abdominothorakal breathing, (-), muscle abdominothorakal breathing (-),
retraction of breathing (-), muscle retraction of breathing(-),
retraction ICS (-) retraction ICS (-)
Palpation Palpable pain(-), tumor (-), Arcus costae Palpable pain (-), tumor (-), Stem
angle < 900, enlargement of ICS (-), Stem fremitus decrease
fremitus decrease
Percution dullness (+) dullness (+)
Auskultation Vesicular (+), Whezzing (-), Ronchi (+) Vesicular (+), Whezzing (-), Ronchi (+)
Interpretation = dullness on
the right side of the lung
Inspection : Ictus cordis isnt be seen.
Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-), sternal lift (-).
Percussion : dull sound
Upper borderline of heart : ICS II left sternal line
Waist of heart : ICS III left parasternal line
Lower right borderline of heart : ICS V right sternal line
Lower left borderline of heart : ICS VI, 2 cm lateral from left mid clavicle line
Auscultation
Aortal valve : S1 & S2 standard, additional sound (-)
Pulmonary valve : S1 & S2 standard, additional sound (-)
Tricuspid valve : S1 & S2 standard, murmur sistolik (-)
Mitral valve : S1 & S2 standard, murmur sistolik (-)
Interpretation : Cardiomegaly
Inspection : symetric, sycatric(-), striae(-), enlargement of vena (-), caput medusa (-).
Auscultation : peristaltic (+)
Palpation :
Superfisial : tight (-), mass (-), epigastrial pain (-)
Deep : abdominal pain (-), liver, kidney, and spleen werent palpable, Murphys sign (-)
Percussion : tympani, side of deaf (-), shifting dullness (-)
Liver : deaf(+), right liver span 11 cm, left liver span 6 cm
Spleen : Throbe space percussion (+) tympani
Interpretation : normal
Extremity Superior Inferior
Oedema -/- -/-
Cold -/- -/-
Capillary Refill <2 s <2 s
Cyanosis -/- -/-
Jaundice -/- -/-
Interpretation : normal
05/10/2017 Hematology 05/10/2017 Kimia
GDS 124mg/dL
Hb 12,9 g/dl
Ureum 58 mg/dL
Ht 40,5 % Creatinin darah 2,29 mg/dL
SGOT 20
Leukosit 13,84 ribu/uL SGPT 19
Natrium 136,6
Trombosit 326 ribu/uL
Kalium 4,02
Chloride 97,2
05/10/2017 Kimia
Kolesterol 116 mg/dl
Trigliserid 89 mg/dl
HDL 19 mg/dl
Interpretation : azotemia, hiperuricemia
LDL 87 mg/dl
Uric Acid 11,2 mg/dl
COR : Apeks jantung bergeser ke lateral
Pinggang jantung mendatar disertai elevasi bronkus kiri
PULMO: corakan vaskuler tampak merapat, meningkat
disertai blurring vaskuler & peribronchial cuffing
Tampak bercak pada perikardial kanan kiri
Penebaln hillus kanan kiri cenderung vaskular
Hemidiagfragma kanan setinggi costa 8 posterior
Sinus costofrenicus janan kiri suram
KESAN :
COR : suspek cardiomegaly (LV,LA)
Gambaran bronkopneumonia curiga disertai edem
pulmonal
Efusi pleura dupleks minimal
Penebalan hillus kanan kiri cenderung vaskular
CTR = A + B / C
CTR = 8 + 14 / 32
CTR = 0,68
CTR > 0.5 Cardiomegaly
Irama : sinus
Regularitas : reguler
Frekuensi : 100 x/minuts
Gelombang p : 0,08 s
Interval PR : 0,16 s
Axis : NAD
Zona Transisi : V5 clockwise
Komplek QRS : 0,04 s
Gelombang Q : Q > 1/3 R pada lead III dan aVF
Segmen ST : ST elevasi (-), ST depresi (-)
Gelombang T : T inverted di lead II, III, Avf, V1-V6
Interpretation = OMI inferior,
Ischemic inferior, antero lateral
Irama : sinus
Regularitas : reguler
Frekuensi : 94x/menit
Gelombang p : 0,04 s
Interval PR : 0,08 s
Axis : NAD
Zona Transisi : -
Komplek QRS : 0,04 s
Gelombang Q : Q >1/3 R di lead III dan aVF
Segmen ST : ST elevasi (-), ST depresi (-)
Gelombang T : T inverted di lead I, II, aVL, V1-V6
Interpretation = OMI
anterior
Dimensi ruang jantung : Membesar di LA dan LV
Dinding LV : Menebal di IVS dan PW
Wall motion : Global Hipokinetik
Katup jantung : TR Moderate, PH Moderate, MR Severe
Fungsi LV sistolik menurun EF 22 %
Fungsi RV sistolik menurun TAPSE 13 mm
Kesan:
Global hipokinetik
Fungsi LV dan RV sistolik menurun
Dilatasi LA dan LV
TR moderate, PH moderate, MR severe
SPECC (+) di LV
RCA
Total oklusi di proksimal
LAD
Stenosis 70% di mid
LCX
Total oklusi di distal
Kesimpulan
CAD 3 VD
Thorax X-Photo
Physical Examination
7. Cardiomegali (LV, LA)
Cor
8. Pleural effusion
3. ICS VI, 2 cm lateral 9. Pulmonal edem
History Taking Lab
from left mid clavicle Echocardiography
1. Chest pain Hematology
line 10. LV+ RV dysfunction
2. Dyspneu deffort 15. Ureum
Pulmo sistolic
11. TR moderate, PH
16. Kreatinin
4. Stem fremitus
moderate 17. Uric acid
deacresed
12. MR Severe
5. Dullness
ECG :
6. Ronchi (+)
13. OMI anterior
PAC :
14. CAD 3 VD
1 2 3
CHF NYHA III CAD 3 VD VHD
2,3,4,5,6,7,9,10 1, 14 11,12
4 5 6
HIPERURISEMIA AZOTEMIA EFUSI PLEURA
17 15, 16 8
Ass: Etiologi : VHD, CAD or IHD
Anatomi : LVH, LAH
Fungsional : NYHA III
IP Dx : BNP and Pro-BNP
IP Tx : Pharmacology
Furosemide 1x 1
Captopril 6,25 mg 1x1
Carvedilol 6,25 mg 2x1
Spironolacton 25 mg 1X1
Laktulosa syr 1 x 1
Non Pharmacology
Low Fat Intake
Low Salt intake
Reduce activity
High fiber Diet
Ip. Mx : Vital sign, ECG
Ip. EX :
Bed Rest/Restriction of physical activity
Reducing Emotional stress
Sit position or a half sleep position
High fiber Diet
Ass : iskemik
IP Dx :-
Ip Tx :
Pharmacology
ISDN subl. 5 mg (complaint chest pain) 3x1
Aspilet 80 mg 1X1
Clopidogrel 75 mg 1X1
Nitrokaf 2,5 mg 2X1
Non pharmacology
PCI
Ip Mx : Vital sign
IpEx :
Bed Rest/Restriction of physical activity
Reduce fatty food
Reducing Emotional stress
Control blood pressure
Routine consumption drugs
Ass : TR moderate
MR severe
Ip Dx : -
Ip Tx :
Non pharmacology
Repair of valvular (consul BTKV)
Pharmacology
Warfarin 5 mg/ day
Ip Mx :
Monitoring hemodynamic system, INR
Ip Ex :
-Education of disease
- Reduce activity
Ass : insufisiensi renal
IP Dx : Check GFR; kidney usg
Ip Tx :
Non pharmacology
diet low in protein and limiting comsumtion salt, control blood pressure
Ip Mx : Vital Sign, GFR, awareness, fluid balance, re-check ureum
and blood creatinin
IpEx :
Reduce activity
Sufficient rest and take medication regularly
Explain about proper daily intake, including type of diet and food
140
GFR = 72
14047 56
=
72 2,29
93 56
= 72 2,29
= 31,58
Ass :
etiology : high intake, excretion disorder
IP Dx : kidney usg
IP Tx :
Pharmacologic
Allopurinol 100 mg 0-0-1
IP Mx:
Uric Acid
IP Ex:
Avoid intern meats high in purine
Avoid sweetened soda beverage
Do Excercise
Stay well hydrated
Ass :
Pleural effusion transudates, exudates
IP Dx : Rivalta test
IP Tx :
Non pharmacologic
O2 canule 3L/minutes
IP Mx: vital sign
IP Ex:
Reduce activity
CAD
VHD
