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7/28/2019 Case Chf Nyha III e.c Hhd
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CHF NYHA III e.c HHD ec. HT Grade II
Indra Pratama Dana
030.07.117
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Name : Mr. B
Age : 85 years old
Address : Tegal Panjang, Blanakan, Subang
Occupation : Labor
Last Education : Primary school
Marital Status : Married
Religion : Moslem
Ethnic : Sundanese
Date of Admission : November 15th 2012
Taken From : Rengasdengklok
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Shortness ofbreath since 2 daysbefore hospitalized
CHIEF
COMPLAINT
Nausea &Vomiting
Lost of appetite
Cough Dizziness
ADDITIONAL
COMPLAINT
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HISTORY OF PRESENT ILLNESSPatient came to Emergency Unit of Karawang Hospital with the
complaint of shortness of breath since 2 days beforehospitalized. 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 ithes using 2 pillowswhen sleeping.
He complained of chest pain when coughing since he feltshortness 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.
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HISTORY OF PRESENTILLNESS
He also complained about feelingnausea and vomiting ifhe ate , and also complained lost of appetite.
He also complained of having both feet swelling a weekbefore admission, especially at night. The swellinggetting worse from day to day. On pressing, the
swelling will form a pit and will back to normal after 4-
6 minutes.
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HISTORY OF PAST ILLNESSSame illness
before (+)
Diabetes
mellitus (-)
Hypertension(+) since 5
years
Asthma (-) Allergy (-) Gastritis (-)
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HISTORY OF FAMILY ILLNESSSame illness
before (-)
Diabetes
mellitus (-)
Hypertension
(-)
Asthma (-) Allergy (-)
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MEDICATION HISTORY
Medicationconsumption
(-)
Bloodtransfusion
(-)
Surgery (-)
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PERSONALSOCIAL HISTORY
Smoke(+)
1 pack/day,alreadystopped
Alcohol(-)
Drugs (-)
Regularyexercise (-)
Tatoos (-)
Herbal
medicine (-)
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GENERAL CONDITION
General Appearances : Moderately ill
Consciusness : Compos Mentis
Weight : 47 kg
Height : 174 cm
BMI : 16.3 kg/m2
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Blood Preassure
170/100 mmHg
Respiratory Rate
18 x/min
Heart Rate
72 x/min
Temperature
36.0o C
VITAL SIGN
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Head Normocephaly
Eyes
Anemic conjunctiva +/+
Swelling -/-
Icteric sclera -/-
Ears
Normotia
Secret -/-
Serumen -/-
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Nose
Septum deviation -
Secret -/-
Concha : normal
Mouth
Dirty mouth -
Dry mouth -
Dry tongue -
Neck Lymph gland is not palpable
Thyroid gland is not palpable
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LUNG
Inspection : Symmetrical, intercostals
retraction (-)
Palpation : Equal vocal fremitus, symmetric breathing
movement
Percussion : Sonor in both lung
Auscultation : Vesicular breath sound in both
lung, Wh -/-, Rh +/+
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HEART
Inspection : Ictus cordis is visible at 6th ICS 2 cm lat LMCS
Palpation : Ictus cordis is palpable at 6th ICS LMCS
Percussion :
Upper R : 3rd ics, LSD
Upper L : 3rd ics, LPS
Bottom R : 5th ics, LSD
Bottom L : 6th ics, 3 cm lat LMCS
Auscultation : Regular I - II heart sound no
murmur and gallop
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Flat abdomen
Caput medusa (-), striae (-)Inspection
Turgor normal
Mass (-) Muscular defense (-)
Hepar and lien enlargement (-)
Ballotement (-/-)
Palpation
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Tympanic
No pain present on abdominalpecussionPercusion
Peristaltic sound (+) normal (2times in 1 minute)Auscultation
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EXTREMITY Warm acrals
Oedema
Palmar erithema (-)/(-)
+ +
+ +
- -
+ +
LABORATORY EXAMINATION
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LABORATORY EXAMINATION(November 15th 2012)
RESULT NORMAL
Hemoglobin
Leukocyte
Trombocyte
Ht
Eritrosit
15.2
9.400
174.000
46.8
4.68
12 17 g%
5000 10000
150.000 450.000
37 48 %
3.8 5.8 jt/mm2
GDSUreum
Creatinin
SGOT
SGPT
Kalium
NatriumChlorida
13735,7
1,43
30
11
3,7
144108
80 140 mg/dl10 45 mg/dl
0.4 1.5 mg/dl
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Thorax Photo
CTR > 50%Enlargement of Left
Ventricle
Enlargement of RightVentricle
Enlargement of Left
Atrium
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RESUME
ANAMNESIS PHYSICAL EXAMINATION THORAX PHOTO
Shortness of breath
Lost of appetite
Nausea Vomiting
Cough
Swelling in both feet
BP : 160/100mmHg
Anemic conjungtiva +/+
Ronchi (+/+)Murmur (+)
Oedem in both feet
CTR > 50%
Enlargement of Left
VentricleEnlargement of Right
Ventricle
Enlargement of Left
Atrium
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DIFFERENTIAL DIAGNOSISCHF NYHA III e.c HHD ec. HT Grade II
CHF e.c Mithral Regurgitation
Coronary Arterial Disease
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WORKING DIAGNOSIS
CHF NYHA III e.c HHD ec. HT Grade II
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SUGGESTED EXAMINATION
Echocardiogram
Lipid profile
Cardiac Enzyme Marker
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TREATMENT Bed Rest
Low salt diet
IVFD NaCl 0,9%
Captopril 3x25
Clopidogrel 1x75
Lasix 2x1 amp
Alprazolam 1x0,5
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PROGNOSISAd vitam: dubia ad malam
Ad fungsionam: dubia ad malam
Ad sanasionam : dubia ad malam
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