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Present by
Fitriani Indah AY
(C111 09 292)
Supervisor :
dr. Pendrik Tandean,SpPD-KKV,FINASIM
• It was felt since ± 1 month ago and got worsen 3 days before admitted to the
hospital. It was experienced while doing minimal activity such as walking to the
bathroom and relieved with resting.
Family History
Vital Sign
Chest 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 /-
• Inspection : Heart apex was not visible
• Palpation : Heart apex was not palpable
• Percussion :Right heart border in right parasternal line,
Left heart border in left midclavicular line
ICS V.
• Auscultation : Heart Sounds : S I/II regular, murmur (+)
Heart sistolik grade 2/6 apex
Extremities
ECG
interpretation
* Rhythm : Sinus rhythm
* Heart rate : 100 bpm
* Regularity : reguler
* Axis : Normoaxis
* P wave : 0,08 s
* PR interval : 0,16 s
* Q pathologies :-
* QRS complex : duration
0,12s, configuration poor R wave
rogression
* ST Segment : 0,08 s
* T wave : 0,12 s
* Conclution :
* Sinus rhythm, HR 83 bpm,
Normoaxis, poor R-wave
progression (V1-V4).
INTERPRETATION
• Cardiomegaly with lung
edema
• Bilateral efusion pleura
• Atherosclerosis aortae
LABORATORIUM 29/9/2014
OGY VALUE
Cardiac diet
Vasodilator
Cedocard 1 mg/hr/sp
ARB
Valsartan 1x80 mg
DISCUSSION
HEART FAILURE
Heart is no longer able to pump an
adequate supply of blood in relation to the
venous return and in relation to the
metabolic needs of the body tissues at the
particular moment
Acute Chronic