Lecturer :

Prof. DR. dr. Moch. Fathoni, Sp. JP(K), FIHA

By: Amelia Kartika Widowati Anastasia Fani Chrisanti Nurotus Saniyah Dewi Ayu Astari P.

Name Age Gender Religion Occupation Address Medical Record Hospitalized

: : : : : : : :

Mr. S 79 years old Male Moslem Manahan, Banjarsari 01189086 April 9th 2013

SHORTNESS OF BREATH

Approximately three days before hospitalized, patient felt the shortness of breath. It appeared on activity and decreased by rest. Patient slept with a pillow. Cold sweating (-), awakened at night because of breathless (+), breathless caused by changing position (-), fainting (-), bloody coughing (-), easily tired (-).

About a week ago patient complained an intermitent epigastric pain. Nausea (+), vomitting (-)

History of heart disease : (+) 5 years ago patient felt chest pain occured more than 20 minutes with burning sensation, occured after activity and not releaved with take a rest, accompanied with cold sweating and naussea. Patient was hospitalized in RSDM. History of hypertension : (+) since 10 years (routine control at Primary Health Care) History of stroke : (-) History of diabetes mellitus : (-) History of Asthma : (-) History of allergy : (-)

EATING BEHAVIOR

2-3 times a day, consumed rice, vegetables, tahu-tempe, occassionally eggs and meat.

LIFE STYLE

Regularly cycling. Didnt smoke. Didnt drink alcohol.

SOSIOECONOMIC

He is an unemployment with 4 children and 5 grandchildren. His wife was dead 2 years ago. He lives with his son. His son works as a labour.

General Condition : Compos Mentis, moderate illness. Vital Signs : BP = 135/80 mmHg HR = 92bpm, reguler, normal intensity RR = 28 times/minute Temperature = 36,2C (axillar) Nutritional status = normoweight

Eyes

: Pale conjunctiva (-/-), Icteric conjunctiva (-/-) Neck : JVP wasnt increased, No enlargement of Lymphnode Thorax : normochest, symmetrical, intercostal retractions (-)

Heart : - Inspection : Ictus cordis was seen at SIC VI Linea Axilaris Anterior Sinistra, left ventricle activity was increased - Palpation : Ictus cordis was palpable at SIC VI Linea Axilaris Anterior Sinistra, heaving (-), thrill (-) - Percussion : 1. Upper limit of the right heart: SIC II, linea parasternalis dextra 2. Bottom right cardiac border: SIC IV, linea parasternalis dextra 3. Upper left cardiac border: SIC II, linea parasternalis sinistra 4. Lower left cardiac border: SIC VI, linea axilaris anterior sinistra Impression: cardiac border was extended caudolateral - Auscultation: 1. Heart Rate: 87 x/ min, regular 2. Intensity of the 1st and 2nd Heart sound were normal, regular, murmurs (-), Gallop (+)

Lungs :

Front Inspection : static and dynamic symmetric Palpation : fumbling fremitus for right = left Percussion : sonor/ sonor Auscultation : Basic vesicular sounds (+/+), crackles (-/-), rales (+/+) in 1/3 basal of the lungs, wheezing (-/-)

Lungs :

Back Inspection : static and dynamic symmetric Palpation : fumbling fremitus for right = left Percussion : sonor / sonor Auscultation: basic vesicular sound (+/+), crackles (-/-), rales (+/+) in 1/3 basal of the lungs , wheezing (-/-)

Abdominal : - Inspection : abdominal wall = chest wall - Auscultation: bowel peristaltic (+) normal - Percussion : tympanic - Palpation : supel, tenderness (-), liver and spleen not palpable, epigastric pain (+) Back : Kyphosis (-), lordosis (-), scoliosis (-) Extremity : - Above : pitting edema (-/-), cold acral (-/-) - Under : pitting edema (-/-), cold acral (-/-)

09/4/2013 Hb HCT RBC 11,9 36 3,72

UNIT g/dl % 106/l

WBC
PLT GDS

5,0
217 100

103/l
103 /l mg/dL

Ureum
Creatinin Natrium Kalium

81
1,2 138 4,2

mg/dL
mg/dL mmol/L mmol/L

Chlorida

113

mmol/L

CTR 67 % Apex grounded Cardiophrenicus angle > 90o Cardiac waist disappear Costophrenic angle is blunt Calsification of aortic knob Fibroinfiltrat with multiple cavities in right lung

CONCLUSION

Cardiomegaly with LVH, LAH Oedem pulmo grade IV Bilateral pleural efussion Suspect of TB

 Anatomic : old myocard infarction anteroseptal wall Functional : Decompensated cordis NYHA IV Etiology : coronary artery disease Risk factor : hypertension, age, male Comorbid : dyspepsia

Half-sitting bedrest O2 3lt/mnt Infus RL 10 dpm Furosemid Inj 20 mg/8 hours Ranitidin Inj. 50 mg/12 hours Spironolakton 25 mg 1-0-0 ISDN 3 x 5 mg Captopril 3x12,5 mg Simvastatin 20 mg 0-0-1 Alprazolam 0,5 mg 0-0-1 Aspilet 80 mg 0-1-0 Antacyd syr 3 x CI

Consult pulmonologist for pleural effusion and diagnose TB Echocardiography

Ad Vitam : dubia ad bonam Ad Sanam : dubia ad malam Ad fungsionam: dubia ad malam