Present by :

Maimanah Mohd Rashid

C 111 05 233
Supervisor :
dr. Idar Mappangara, SpPD, SpJP, FIHA

Name
MR number
Age
Gender
Admitted

Case Presentation . Cardiology Department

2009

:
:
:
:
:

Mr P
404414
27 years old
Male
6th October
2009

September 26, 2016

Chief complaint : Breathlessness

History taken :

Experienced since 1 week ago, getting worse if

he had a moderate activity. He usually used two
to three pillows at night, but never awake due to
this complaint. Cough (+) sometimes, chest
pain (-).
No fever, but was having fever 1 week ago and
have been admitted to hospital with Typhoid
fever.
Case Presentation . Cardiology Department
2009

September 26, 2016

History of breathlessness since 3 months

old, but it become more frequent and

worsen at 12 years old. It happened
suddenly without any activity-induced.
Family history of heart disease (-)
Normal history of antenatal & prenatal

Case Presentation . Cardiology Department

2009

September 26, 2016

General appearance

Moderate illness/Underweight/Conscious
Vital sign

BP
: 100/70
Pulse
: 110 bpm, regular
Resp rate
: 30 tpm
Temp
: 36.8 c

Case Presentation . Cardiology Department

2009

September 26, 2016

Head

Eyes : Anemia (-), Icterus (-), Cyanosis (-)

Neck : Mass (-), Tenderness (-), JVP R-1 cmH 2O
Thorax

Inspection
Palpation
Percussion

: Symmetric, Pigeon chest

: Mass (-), Tenderness (-)
: Sonor

Auscultation : BS Vesicular, Rh

Case Presentation . Cardiology Department

2009

, Wh -/-

September 26, 2016

Cardiac

Inspection
: Ictus cordis visible
Palpation: Ictus cordis palpable
Percussion
: Kesan melebar
Auscultation : Regular heart sound (I/II),
systolic murmur
Abdomen

Inspection
Palpation
Percussion
Auscultation
Extremities
+

/+

:
:
:
:

Flat, following breath movement

Liver and spleen unpalpable
Tympani
Peristaltic (+) normal

: Pretibial & dorsum pedis edema

Case Presentation . Cardiology Department

2009

September 26, 2016

Case Presentation . Cardiology Department

2009

September 26, 2016

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

Lead II : Sinus Takikardi

Sinus rythm
HR
P wave
PR Interval
QRS complex

:
:
:
:

107 tpm
0,08 sec
0,12 sec
0,08 sec

Case Presentation . Cardiology Department

2009

September 26, 2016

10

Axis : Right Axis Deviation (RAD)

Lead I

Lead aVF

Case Presentation . Cardiology Department

2009

September 26, 2016

11

Lead I : Complete Right Bundle Branch Block (c

RBBB)
R
r
S

rSR complex
QRS complex > 0,12 sec
Case Presentation . Cardiology Department
2009

4 small boxes

September 26, 2016

12

T Waves : T-inverted in lead V4, V5, V6

Lead V4

Lead V5

Lead V6
Interpretation :
Ischeamic Apicolateral Wall
Case Presentation . Cardiology Department
2009

September 26, 2016

13

RA, RV dilatation
RVH (+)
Good contractility of LV,

EF 66%
Pulmonal Regurgitation
Moderate
Tricuspid Regurgitation
Severe, PH 53 mmHg
ASD 3,6cm
(bidirectional shunt)
Case Presentation . Cardiology Department
2009

September 26, 2016

14

Case Presentation . Cardiology Department

2009

September 26, 2016

15

Cardiac Diet
O2 2-3 L/m (if needed)
IVFD NaCl 0,9% 10 dpm
Farsix 40

1-0-0

Carpiaton-25

1-0-0
Digoxin 0,25mg
0-0-1
Dorner
1-0-1
Aspilet 80
0-1-0

Case Presentation . Cardiology Department

2009

September 26, 2016

16

A failure of proper closure of

the foramen ovale or by a
defect in the septum
secundum, which allows
abnormal mixing of
oxygenated and deoxygenated
blood. The severity of the
symptoms depends on the size
and location of the defect with
mild cases being
asymptomatic until adulthood.
The etiology is unkown, but
predesposition factors are
genetic & enviroment ;
especially antenatal.
Case Presentation . Cardiology Department
2009

September 26, 2016

17

Patent foramen ovale (PFO) : associate with

unexplained thrombotic stroke in young adult

Secundum atrial septal defects : most
common, usually central.
Primium atrial septal defect : defects locate
low down in the atrial septum, thus have an
abnormality of the atrioventricular junction.
Sinus venosus atrial septal defects : occur in
the upper part of atrial septum, usually
adjecent to the superior vena cava.
Case Presentation . Cardiology Department
2009

September 26, 2016

18

Related to the size of the intracardiac shunt.

Individuals with a larger shunt tend to present

with symptoms at a younger age.
The symptoms are :
- Dyspnea on exertion (shortness of breath
with minimal exercise)
- Congestive heart failure
- Cerebrovascular accident (stroke)
* It may appear unsymptomatic, and only
revealed during the general medical check up
Case Presentation . Cardiology Department
2009

September 26, 2016

19

ECG : Right Bundle Branch Block (RBBB),

RAD (in ostium secundum type), LAD (in

ostium primum type).
Chest x-ray : Right ventricular volume
loading.
Echocardiography : demonstrate all forms
of ASD and differentiates easily between
them.
Case Presentation . Cardiology Department
2009

September 26, 2016

20

Medical management : digoxin, diuretics

Infection control
Surgical repair

Indication :
- Cardiac enlargement, right ventricle dilatation,
pulmonal hypertension
- History of transiet ischeamic
(especially for large defect > 40mm)
Device closure (Septal Occluder) for small

defect (< 40mm)

Case Presentation . Cardiology Department
2009

September 26, 2016

21

Case Presentation . Cardiology Department

2009

September 26, 2016

22