case chf nyha iii e.c hhd

7/28/2019 Case Chf Nyha III e.c Hhd

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CHF NYHA III e.c HHD ec. HT Grade II

Indra Pratama Dana

030.07.117


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Name : Mr. B

Age : 85 years old

Address : Tegal Panjang, Blanakan, Subang

Occupation : Labor

Last Education : Primary school

Marital Status : Married

Religion : Moslem

Ethnic : Sundanese

Date of Admission : November 15th 2012

Taken From : Rengasdengklok


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Shortness ofbreath since 2 daysbefore hospitalized

CHIEF

COMPLAINT

Nausea &Vomiting

Lost of appetite

Cough Dizziness

ADDITIONAL

COMPLAINT


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HISTORY OF PRESENT ILLNESSPatient came to Emergency Unit of Karawang Hospital with the

complaint of shortness of breath since 2 days beforehospitalized. The symptom appeared during his normal

activities such as go to the toilet. The symptom appeared when

he lies flat on his back, and because of ithes using 2 pillowswhen sleeping.

He complained of chest pain when coughing since he feltshortness of breath. He often wakes up in the middle of the

night because of his breathlessness.The breathlessness is not affected by cold, dust, or emotion, and

no wheezing is heard.


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HISTORY OF PRESENTILLNESS

He also complained about feelingnausea and vomiting ifhe ate , and also complained lost of appetite.

He also complained of having both feet swelling a weekbefore admission, especially at night. The swellinggetting worse from day to day. On pressing, the

swelling will form a pit and will back to normal after 4-

6 minutes.


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HISTORY OF PAST ILLNESSSame illness

before (+)

Diabetes

mellitus (-)

Hypertension(+) since 5

years

Asthma (-) Allergy (-) Gastritis (-)


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HISTORY OF FAMILY ILLNESSSame illness

before (-)

Diabetes

mellitus (-)

Hypertension

(-)

Asthma (-) Allergy (-)


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MEDICATION HISTORY

Medicationconsumption

(-)

Bloodtransfusion

(-)

Surgery (-)


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PERSONALSOCIAL HISTORY

Smoke(+)

1 pack/day,alreadystopped

Alcohol(-)

Drugs (-)

Regularyexercise (-)

Tatoos (-)

Herbal

medicine (-)


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GENERAL CONDITION

General Appearances : Moderately ill

Consciusness : Compos Mentis

Weight : 47 kg

Height : 174 cm

BMI : 16.3 kg/m2


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Blood Preassure

170/100 mmHg

Respiratory Rate

18 x/min

Heart Rate

72 x/min

Temperature

36.0o C

VITAL SIGN


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Head Normocephaly

Eyes

Anemic conjunctiva +/+

Swelling -/-

Icteric sclera -/-

Ears

Normotia

Secret -/-

Serumen -/-


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Nose

Septum deviation -

Secret -/-

Concha : normal

Mouth

Dirty mouth -

Dry mouth -

Dry tongue -

Neck Lymph gland is not palpable

Thyroid gland is not palpable


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LUNG

Inspection : Symmetrical, intercostals

retraction (-)

Palpation : Equal vocal fremitus, symmetric breathing

movement

Percussion : Sonor in both lung

Auscultation : Vesicular breath sound in both

lung, Wh -/-, Rh +/+


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HEART

Inspection : Ictus cordis is visible at 6th ICS 2 cm lat LMCS

Palpation : Ictus cordis is palpable at 6th ICS LMCS

Percussion :

Upper R : 3rd ics, LSD

Upper L : 3rd ics, LPS

Bottom R : 5th ics, LSD

Bottom L : 6th ics, 3 cm lat LMCS

Auscultation : Regular I - II heart sound no

murmur and gallop


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Flat abdomen

Caput medusa (-), striae (-)Inspection

Turgor normal

Mass (-) Muscular defense (-)

Hepar and lien enlargement (-)

Ballotement (-/-)

Palpation


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Tympanic

No pain present on abdominalpecussionPercusion

Peristaltic sound (+) normal (2times in 1 minute)Auscultation


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EXTREMITY Warm acrals

Oedema

Palmar erithema (-)/(-)

+ +

+ +

- -

+ +

LABORATORY EXAMINATION


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LABORATORY EXAMINATION(November 15th 2012)

RESULT NORMAL

Hemoglobin

Leukocyte

Trombocyte

Ht

Eritrosit

15.2

9.400

174.000

46.8

4.68

12 17 g%

5000 10000

150.000 450.000

37 48 %

3.8 5.8 jt/mm2

GDSUreum

Creatinin

SGOT

SGPT

Kalium

NatriumChlorida

13735,7

1,43

30

11

3,7

144108

80 140 mg/dl10 45 mg/dl

0.4 1.5 mg/dl


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Thorax Photo

CTR > 50%Enlargement of Left

Ventricle

Enlargement of RightVentricle

Enlargement of Left

Atrium


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RESUME

ANAMNESIS PHYSICAL EXAMINATION THORAX PHOTO

Shortness of breath

Lost of appetite

Nausea Vomiting

Cough

Swelling in both feet

BP : 160/100mmHg

Anemic conjungtiva +/+

Ronchi (+/+)Murmur (+)

Oedem in both feet

CTR > 50%

Enlargement of Left

VentricleEnlargement of Right

Ventricle

Enlargement of Left

Atrium


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DIFFERENTIAL DIAGNOSISCHF NYHA III e.c HHD ec. HT Grade II

CHF e.c Mithral Regurgitation

Coronary Arterial Disease


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WORKING DIAGNOSIS

CHF NYHA III e.c HHD ec. HT Grade II


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SUGGESTED EXAMINATION

Echocardiogram

Lipid profile

Cardiac Enzyme Marker


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TREATMENT Bed Rest

Low salt diet

IVFD NaCl 0,9%

Captopril 3x25

Clopidogrel 1x75

Lasix 2x1 amp

Alprazolam 1x0,5


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PROGNOSISAd vitam: dubia ad malam

Ad fungsionam: dubia ad malam

Ad sanasionam : dubia ad malam


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case chf nyha iii e.c hhd

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