CHF NYHA III e.c HHD ec.

HT Grade II

Indra Pratama Dana 030.07.117

Name Age Address Occupation Last Education Marital Status Religion Ethnic

: Mr. B : 85 years old : Tegal Panjang, Blanakan, Subang : Labor : Primary school : Married : Moslem : Sundanese

Date of Admission Taken From

: November 15th 2012 : Rengasdengklok

 Shortness of breath since 2 days before hospitalized

Nausea & Vomiting Lost of appetite Cough Dizziness

CHIEF COMPLAINT

ADDITIONAL COMPLAINT

HISTORY OF PRESENT ILLNESS

Patient came to Emergency Unit of Karawang Hospital with the complaint of shortness of breath since 2 days before hospitalized. 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 it hes using 2 pillows when sleeping. He complained of chest pain when coughing since he felt shortness 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.

HISTORY OF PRESENT ILLNESS

He also complained about feeling nausea and vomiting if he ate , and also complained lost of appetite. He also complained of having both feet swelling a week before admission, especially at night. The swelling getting worse from day to day. On pressing, the swelling will form a pit and will back to normal after 46 minutes.

HISTORY OF PAST ILLNESS

Same illness before (+) Diabetes mellitus (-)
Hypertension (+) since 5 years Gastritis (-)

Asthma (-)

Allergy (-)

HISTORY OF FAMILY ILLNESS

Same illness before (-) Diabetes mellitus (-) Hypertension (-)

Asthma (-)

Allergy (-)

MEDICATION HISTORY

Medication consumption (-)

Surgery (-)

Blood transfusion (-)

PERSONAL SOCIAL HISTORY

Smoke(+) 1 pack/day, already stopped Drugs (-)

Tatoos (-)

Alcohol (-)

Regulary exercise (-)

Herbal medicine ()

GENERAL CONDITION
General Appearances Consciusness Weight Height BMI : Moderately ill : Compos Mentis : 47 kg : 174 cm : 16.3 kg/m2

Blood Preassure 170/100 mmHg

Respiratory Rate 18 x/min

VITAL SIGN

Heart Rate 72 x/min

Temperature 36.0o C

Head Eyes Ears

Normocephaly

Anemic conjunctiva +/+ Swelling -/ Icteric sclera -/-

Normotia Secret -/ Serumen -/-

Nose Mouth Neck

Septum deviation Secret -/ Concha : normal

Dirty mouth Dry mouth Dry tongue -

Lymph gland is not palpable Thyroid gland is not palpable

LUNG
Inspection Palpation Percussion : Symmetrical, intercostals retraction (-) : Equal vocal fremitus, symmetric breathing movement : Sonor in both lung

Auscultation : Vesicular breath sound in both

lung, Wh -/-, Rh +/+

HEART
Inspection
Palpation Percussion

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

: Ictus cordis is palpable at 6th ICS LMCS :

Upper R
Upper L

: 3rd ics, LSD

: 3rd ics, LPS

Bottom R : 5th ics, LSD

Bottom L : 6th ics, 3 cm lat LMCS

Auscultation : Regular I - II heart sound murmur and gallop no

Inspection

Flat abdomen Caput medusa (-), striae (-)

Palpation

Turgor normal Mass (-) Muscular defense (-) Hepar and lien enlargement (-) Ballotement (-/-)

Percusion

Tympanic No pain present on abdominal pecussion

Auscultation

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

EXTREMITY
Warm acrals
+ + + +

Oedema

Palmar erithema (-)/(-)

LABORATORY EXAMINATION
(November 15th 2012)
RESULT
Hemoglobin Leukocyte Trombocyte Ht Eritrosit GDS Ureum Creatinin SGOT SGPT Kalium Natrium Chlorida
15.2 9.400 174.000 46.8 4.68 137 35,7 1,43 30 11 3,7 144 108

NORMAL
12 17 g% 5000 10000 150.000 450.000 37 48 % 3.8 5.8 jt/mm2 80 140 mg/dl 10 45 mg/dl 0.4 1.5 mg/dl <40 u/l <40 u/l 3,5 5,6 134-145 100-110

Thorax Photo
CTR > 50% Enlargement of Left Ventricle Enlargement of Right Ventricle Enlargement of Left Atrium

RESUME
ANAMNESIS Shortness of breath Lost of appetite Nausea Vomiting Cough Swelling in both feet PHYSICAL EXAMINATION BP : 160/100mmHg Anemic conjungtiva +/+ Ronchi (+/+) Murmur (+) Oedem in both feet THORAX PHOTO CTR > 50% Enlargement of Left Ventricle Enlargement of Right Ventricle Enlargement of Left Atrium

DIFFERENTIAL DIAGNOSIS
CHF NYHA III e.c HHD ec. HT Grade II CHF e.c Mithral Regurgitation

Coronary Arterial Disease

WORKING DIAGNOSIS

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

SUGGESTED EXAMINATION

Echocardiogram

Lipid profile

Cardiac Enzyme Marker

TREATMENT
Bed Rest Low salt diet IVFD NaCl 0,9% Captopril 3x25 Clopidogrel 1x75 Lasix 2x1 amp Alprazolam 1x0,5

PROGNOSIS
Ad vitam: dubia ad malam

Ad fungsionam: dubia ad malam

Ad sanasionam : dubia ad malam