28 OCTOBER 2013

Doctor in Charge:
Dr. Enita R. Sp PD

Chief complain: Shortness of Breath
Patient complain that he had shortness of breath
since one month ago. Shortness of breath happens
every day and become heavier at night. Shortness of
breath happen when the patient do his activity. Before
the patient came to the hospital, he said his complaint
happened if he had activity but now his complaint
become heavier and make him hard to talk.The patient
said that he couldnt sleep even with three pillows under
his head. The patient said that he felt fatigue in any
activity within 1 month. He said that his legs getting
bigger in this one month and made him hard to walk.

Summary of Data Base
And then he felt his heart beat so fast. He
complaint chest pain and the pain radiated
through his back.

History of Illness: Same complaint (+)
HT (+) smoke(-)

History of family illness: HT (+), Heart
Disease (+)
Physical examination
General appearance moderate ill GCS: 456
BP = 170/100 mmHg HR: 105 x/min reg
highly(+)
Body weight: 85 kg
RR: 35 x/min Temp: 36,5C
Fast and shallow

Height: 165 cm
Eyes Anemic : -/- Icteric : +/+
Neck P> JVP (R+7 cm H2O), P> Lymph node (-)

Thorax
cor
Ins :ictus: invisible,
Pal: ictus cordis palpable, thrill (-)
Per:
Left Heart Margin: midclavicula line sinistra ICS 5
Right Heart Margin: sternal line dextra
Cardiac waist:
Aus: reguler, murmur: (+), gallop (+)

Lung
+ + + + + + - -
+ + + + + + - -
- - - - + + - -
`111 Ins : convex, ascites
Aus: BS (+) 8 N
Per :
Pal : organomegaly (-), mass (-), fluid wave (+)

Ext Pitting Ed: +/+
+/+
Lab Value Lab Value
Leukocyte 10.500 4000;10.500/L Gran# 8.20 2,50-7,00 ribu/ul
RDW-CV 17.2 11.5-14.7 Limfosit # 2.9 1,25-4,0 ribu/ul
Hemoglobin 15.5 14.00-18.00 GDS 149 <200 mg/dl
eritrosit 5.74 4,506,00 SGOT 161 0-46U/L
Hematokrit 47.5 42,00- 52,00 SGPT 77 0-45U/L
MCV 86,5 80,0-97,0 -
MCH 32,0 27,0-32,0 Ureum 30 10-50
MCHC 37,3 32,0-38,0 Creatinine 1.2 0,6-1,2mg/dL
RDW-CV 17,2 11,5-14,7 LDH 2098 10-50mg/dL
Gran % 66.0 50,0-70,0 CKMB 77
Limfosit% 23.6 25,0-40,0
MID% 10.4 4,0-11,0
CUE AND CLUE PROBLEM
LIST
INITIAL
DIAGNOSE
PLANNING
DIAGNOSE
PLANNING THERAPY
P mon
1. male/ 58 y.o
Anamnesa:
-Dispneu
-PND
-Fatigue on
activity
-Ortopneu
-Chest pain
-Tachicardia
Physical
examination:
BP: 170/100
mmHg
HR: 105x/mnt
RR:35x/mnt
-Icteric sclera
(+/+)
- JVP increase
+ 7cm
-ictus cordis
palpable
-pitting edem
-Rhonki (+)
1. N-
STEMI
1.1
hypertensive
heart disease
1.2 coronary
artery disease
Ro thorax
Echocardi
ografi
LDH,CKM
B,
bilirubin
direct,
bilirubin
indirect,
SGOT,
SGPT












Non
Farmacologic:
-Low salt diet
-No smoking and
alcohol
- prevent obesity
- prevent stress
Farmacologic:
Venflon (+)
Drip Furosemid
(iv)/ nitrogliserin
(iv)
PO:
Spironolakton 2x1
tab
ISDN 3x1 tab
EKG
monito
ring,
vital
sign,
Sa O2,
fluid
balanc
e ,
CKMB
, LDH


CUE AND CLUE PROBLEM
LIST
INITIAL
DIAGNOSE
PLANNING
DIAGNOSE
PLANNING THERAPY
P mon
Lab diagnostic:
LDH: 2098
CKMB: 77
SGOT: 161
SGPT: 68



2. male 58 y.o
TD: 170/100

Family history of
hypertension (+)














Hypertens
ion stage
2



















2.1
2.2











Blood
pressure
















Captopril 3x1 tab
(12,5 mg)






















Objecti
ve,
blood
pressu
re
routine














CUE AND CLUE PROBLEM
LIST
INITIAL
DIAGNOSE
PLANNING
DIAGNOSE
PLANNING THERAPY
P mon
1. HF
2. N-
STEMI
3. Acute
lung
Oede
m
4. Ascite
s
5. HT st
II
1. A
2. MONACO
3. S above

Thank you