Chf nyha iI ec. Stemi (ST-elevasi mikard infark)

CHF fc III ec Mitral Stenosis

Nur Ikhwaini binti Ismail

(C111 09 851)

Supervisor :

Prof. Dr. dr. Ali Aspar Mappahya, SpPD,

Sp.JP(K), FIHA, FAsCC, FINASIM, FICA

CASE PRESENTATION

Department of Cardiology and Vascular Medicine

Medical Faculty of Hasanuddin University

Makassar

2014

Patient Identity

Name: Mrs. S

Age : 30 years old

Gender : Female

Address : Dusun Lamaeto

MR: 658915

Day of Admission : April 13rd 2014

HISTORY TAKING

Chief Complaint : shortness of breath (SOB)

It was felt since 5 years ago and worsen in 1 month before admitted to the hospital, accompanied by heart palpitation and worsen while doing some activities.

Cough (+) with transparent, non blood-mixed mucus (+), common cold (+) in which often relapse since childhood

defecation normal, urinary normal.

Fever (-), Nausea (-), vomitting (-), epigastric pain (+),

History of having rheumatic fever at the age of 15 which was poorly treated

Patient claimed that she slept better by using more than a pillow, and easily woke up in the middle of sleep due to SOB. No chest pain nor faint occured.

Past Medical History

History of rheumatic fever which was poorly treated at the age of 15

History of heart disease (-)

History of DM (-)

History of smoking (-)

History of hypertension (-)

Family History

History of heart disease in family (-)

General Status

Compos mentis/Moderate illness/ Well nourished

Nutritional Status: Normal

Weight : 47 kg

Height : 159 cm

BMI : 18.5 kg/m2

Vital Sign

Blood Pressure: 90/50mmHg

Heart Rate: 110 bpm

Respiratory Rate : 24 bpm

Temperature : 36.6 0C (axilla)

PHYSICAL EXAMINATION

Head and Neck Examination

Eye : Conjunctiva anemic (-/-),Sclera icteric (-/-)

Lip : Cyanosis (-)

Neck : JVP R+1 cmH20

Thorax Examination

Inspection : Symmetric between left and right chest.

Palpation : No mass, no tenderness.

Percussion : Sonor between left and right chest, lung-liver border in ICS IV right anterior.

Auscultation: Respiratory sound: Vesicular

Additional sound : Ronchi -/-, Wheezing -/-

Heart examination :

Inspection : visible ictus cordis (+)

Palpation : palpable ictus cordis (+)

Percussion : Upper heart : ICS II

parasternalis linea sinistra

Bottom heart : ICS IV

parasternalis linea dextra

left Heart : ICS IV midclavicularis linea sinistra

Right heart : ICS IV parasternalis linea dextra

Auscultation : heart sound I/II regular, diastolic murmur (+) heard at the apex ICS 3/4

Abdomen examination

Inspection : flat, according to breath movement

Auscultation : peristaltic (+) normal

Palpation : mass tumor (-), pain (-), liver and spleen are impalpable

Percussion : thympany (+), ascites (-)

Extremities examination

Pretibial oedema -/-

Electrocardiogram (ECG)

14/4/2014

Sinus pause, HR 110 bpm, AFRVR, RAD, ST- depression on leads II,III and avF

Mitral Stenosis

There is atrial fibrillation. No P waves are visible. The rhythm is irregularly irregular (random).

There is the suggestion of right ventricular hypertrophy. Right axis deviation and deep S waves in the lateral leads. Another important feature of right ventricular hypertrophy not shown here is a dominant R wave in lead V1.

The combination of Atrial Fibrillation and Right Axis Deviation on the ECG suggests the possibility of mitral stenosis.

9

ECG interpretation

Rhythm: Sinus pause

Heart rate: 110 bpm

Regularity : irreguler- AFRVR ( atrial fibrillation with rapid

ventricular response of 110 bpm)

Axis: Right Axis Deviation (RAD)

P wave: 0,08 s

PR interval: difficult to be evaluated

Q pathologist : -

QRS complex: Duration 0,08 s

ST Segment: ST depression on leads II, III, aVF

T inverted : -

Conclusion : HR 110 x/minute, AFRVR, RAD

Radiologic findings

Increased bronchovascularisation

No specific processes on both lung areas

Enlargement of Cor with CTI 0.67, raise of pulmonalis cone, raise of left auricle, lifted apex and diminished aorta

Both sinus and diaphragm are in good condition

All bones in intact

Conclusion : Cardiomegaly with mitral heart disease appearance.

LABORATORIUM

HEMATOLOGYRESULTNORMAL VALUEUNITWBC6.44,00-10,0(10/UI)RBC5.124,00-6,00(106/UI)HGB15.712,0-16,0(gr/dL)HCT47.737,0-48,0(%)PLT167150-400(103/uL)GDS136140Mg/dLUric acid6.12,4-5,7Mg/DlCreatinine0.6