Case Bareng Iyem

8/12/2019 Case Bareng Iyem

1/15

CHAPTER II

CASE REPORT

II.1 IDENTIFICATION

Name : Mr. Fa

Age : 63 years old

Sex : Male

Address : Jl. Psi lautan lrg. Cemara Kel. 36 ilir Palembang

Status : Married

Ou!ation : "abour

#eligion : $slamAdmitted to %os!ital : &%ursday' Otober (nd())*

II.2 ANAMNESIS (Autoanamnesis dan Alloanamnesis (housei!e""

C%ie+ Com!laint

S%ortness o+ breat% so %ea,y sine - day be+ore admission.

istory o+ illness

/ -) days be+ore admission' t%e !atient om!lained o+ %a,ing s%ortness o+

breat%' it 0as de!end on !osition' !atient +ell more om+ortable i+ %e sit do0n' and

de!end on ati,ity' %e 0ill s%ortness o+ breat% a+ter go to toilet' !atient 0ould not

om!lained it i+ %e 0as ta1e a rest. 2ut no de!end on 0eat%er and not +ollo0ing o+

ngi1 ,oie. e 0ill be more om+ortable 0it% ( 4 3 !illo0s 0%en slee! time. e

denies any om!laint 0a1e u! in slee! time 0it% s%ortness o+ breat% and %est !ain.

e also denies any om!laint o+ %eart !al!itation' oug%' +e,er' or o,er s0eating

during nig%t time. e also 0as om!laint s0ell in bot% o+ lo0er extremity. S0elling

in !al!ebra su!erior 0as denied. e 0as om!laint iteri in s1in and eyes. e %as no

om!laint nausea and ,omitting. &%ere 0as disorder in urinate' turn yello0 tea urine'

but no disorder in de+eation.

/ - day be+ore admission' t%e !atient om!lained o+ %a,ing s%ortness o+

breat% so %ea,y' it 0as de!end on !osition' !atient +ell more om+ortable i+ %e sit

3


2/15

do0n' and de!end on ati,ity' !atient 0ould not om!lained it i+ %e 0as ta1e a rest.

2ut no de!end on 0eat%er and not +ollo0ing o+ ngi1 ,oie. e 0ill be more

om+ortable 0it% ( 4 3 !illo0s 0%en slee! time. e denies any om!laint 0a1e u! in

slee! time 0it% s%ortness o+ breat% and %est !ain. e also denies any om!laint o+

%eart !al!itation' oug%' +e,er' or o,er s0eating during nig%t time. e also 0as

om!laint s0ell in bot% o+ lo0er extremity. S0elling in !al!ebra su!erior 0as denied.

e 0as om!laint iteri in eyes' yello0 s1in 0as denied. e %as no om!laint

nausea and ,omitting. &%ere 0as no disorder in urinate and de+eation.

istory o+ !ast illness

5 istory o+ %eart disease sine / - years ago and %as admitted to %os!ital -(times.

5 istory o+ %y!ertension sine / - years ago' unontrolled.

5 istory o+ diabetes mellitus 0as denied

5 istory o+ 1idney disease 0as denied

5 istory o+ tuberulosis 0as denied

Family isease istory

istory o+ t%e same sym!toms in %is +amily 0as denied.

II.# PH$SICA% E&AMINATION

7eneral examination

-. 7eneral ondition : si1

(. Si1ness ondition : moderate si1ness

3. Consiousness : om!os mentis

8. 2lood !ressure : -9);) mmg

9. Pulse rate : *) timesminute' reguler

6. #es!iration rate : (* timesminute


3/15

*. e%ydration : =5>

;. Nutrition : #2? @ ---

$m!ressi,e: O,ernutrition

-). ?eig%t : 9* 1g

--. eig%t : -9* m

S!esi+i examination

-. S1in

S1in olor is !ue

Normal !igmentation

B+loresense' iteri' sianoti or !ale on !alm and !lantar =5>

Sar =5>

y!er%idrosis =5>

Normal %air gro0t%

7ood turgor

Bnoug% +at layer

?et or dry in !al!itation =5>

Nodul subutan =5>

(. "ym!% gland

&%ere 0ere no enlargment o+ t%e lym!% nodes on submandibular' ne1'

axillaries and inguinal.

3. ead

O,al' symmetrial

Pu++y +ae =5>

e+ormity =5>

Malar ras% =5>

9


4/15

Alo!eia =5>

8. Bye

B1so!%talmus and eno!%talmus =5>

Bdematous !al!ebra su!erior =5>

Pale o+ onunti,a !al!ebra =5>

Slera iteri =D>

9. Nose

B!istaxis =5>

Normal nasal se!tum

Normal muous layer

6. Bar

7ood %earing

Normal bot% o+ meatus austius externus

Stomatitis =5>

Pa!il atro!%y =5>

7um bleeding =5>

Fetor oris =5>

*. Ne1

&%yroid gland not !al!able' t%yroid bruit =5>

Jugular ,ein !ressure =9D(> m()

y!ertro!%y o+ musulus sternoleidomastoideus =5>' sti++ness =5>

6


5/15

;. &%orax

Normal s%a!e

Bxtended interostal setion =5>

#etration =5>

Eenetasis =5>

S!ider ne,i =5>

-). "ung

Anterior o+ t%e lung

$ns!etion : symetrial o+ stati and dynami rig%t and le+t are eual

Pal!ation : #ig%t and le+t lung stem+remitus are eual

Perussion : sonor on le+t and rig%t lung

Ausultation : ,esiular =D> normal' so+t 0et rales on t%e base o+ le+t

and rig%t lung' 0%eeGing =5>

Posterior o+ t%e lung

$ns!etion : symetrial o+ stati and dynami rig%t and le+t are eual

Pal!ation : #ig%t and le+t lung stem+remitus are eual

Perussion : sonor on le+t and rig%t lung


6/15

Ausultation : ,esiular =D> normal' so+t 0et rales on t%e base o+ le+t

and rig%t lung' 0%eeGing =5>

--. Cor

$ns!etion : itus ordis 0as seen in $CS E

Pal!ation : itus ordis 0as !al!able in $CS E

Perussion : u!!er boundary o+ or is $CS $$$' le+t boundary o+ or

is "AA and rig%t boundary o+ or is "MC dextra.

Ausultation : %eart rate : *) timesminutes' regular' murmur =D>

Sistoli1 on mitral and trius!id ,al,e' gallo! =5>

-(. Abdomen

$ns!etion : +lat' ,enetation =5>'

Pal!ation : no !ain in !al!ation' s!leen is un!al!able' li,er is !al!able

3 +ingers under arus ostae

Perussion : tym!any' s%i+ting dullness =5>

Ausultation : bo0el sound =D> normal

-3. Bxternal genitalia : not examined

*


7/15

-8. H!!er extremity

Pain on oint =5>

Pale on +inger =5>

Bryt%ema o+ !alm =5>

Pitting edema =5>

Clubbing +inger =5>

&remor =5>

Normal !%ysiologial re+lex

-9. "o0er extremity

Earies =5>

Minimal edema =D>

Pain on oint =5>

Pale on +inger =5>

Normal !%ysiologial re+lex

II.' ADDITIONA% E&AMINATION

Bletroardiogra!%y =( otober ())*>

AF dan axis 0as normal' # @ *; timesminute' P 0a,e inestimable'

I#S om!lex@ )')* seonds' #S E- -' SE- D #E9E6 39' I !at% E3 4

E9.

$m!ressi,e: AF D OM$ lateral.

"aboratory Findings =( otober ())*>2lood analysis

emoglobin : --'; gdl = N: -85-* gdl >

ematorite : 39 ,ol = N: 8)58* ,ol >

"eu1oyte : 6.-))mm = N: 9)))5-)))) mm >

;


8/15

BS# : -* mm%r = N: -) mm%r >

&romboyte : -)-.))) = N: ()))))59))))) mm >

i++. Count : )()

"5%olesterol : (3 mgdl = N: 99 >

""5%olesterol : *( mgdl = N: -3) >

&riglyerida :

Hreum : (8 mgdl = N: -953; >

Creatinin : -'( mgdl = N: )';5-'3 >

Sodium : -39 mmoll = N: -395-99 mmoll >

Potassium : 3'3 mmoll = N: 3'959'9 >

#ontgen t%orax =6 otober ())*>

$m!ressi,e: ardiomegaly and ongesti,e !ulmonum

Ad,ise: HS7 o+ ardia.

II. RES)ME

A man 0%o %as initial name Mr. Fa' 63 years old' admitted to %os!ital in

&%ursday' (nd otober ())*' 0it% %ie+ om!laint s%ortness o+ breat% so %ea,y sine -

day be+ore admission.

/ -) days be+ore admission' t%e !atient om!lained o+ %a,ing s%ortness o+

breat%' it 0as de!end on !osition' !atient +ell more om+ortable i+ %e sit do0n' and

de!end on ati,ity' %e 0ill s%ortness o+ breat% a+ter go to toilet' %e 0ould not

om!lained it i+ %e 0as ta1e a rest. e 0ill be more om+ortable 0it% ( 4 3 !illo0s

0%en slee! time. e also 0as om!laint s0ell in bot% o+ lo0er extremity. e 0as

-)


9/15


10/15

7allo! S3 =5>

$nreasing JEP =D>

#e+lu1s %e!atougular =D>

Minor Criteria

Bdema o+ extremity =D>

Coug% in nig%t time =5>

is!nea de++ort =D>

e!atomegaly =D>

Pleural e++usion =5>

erease ,ital a!aity =5> &aiardia =-() timesminute> =5>

II.* +OR,IN- DIA-NOSIS

C%roni %eart +ailure e. M$ 4 MS D %y!ertension stage -

II. DIFFERENTIA% DIA-NOSIS

C%roni %eart +ailure e. D %y!ertension stage -

C%roni %eart +ailure e. C D %y!ertension stage -

II./ TREATMENT

Non!%arma%ology

2edrest

Cor diet $E

al+ sitted !osition

P%arma%ology

$EF 9 gtt minutemiro

Furosemide am! -x-

-(


11/15

Ca!to!ril tab 3x(9 mg

S!ironolatone tab -x(9 mg

Aetosal tab -x-)) mg

Ome!raGole tab -x-

"axadyn syr 3x-C

KS# -x-

II.0 P%ANNIN-

B%oardiogra!%y

HS7 o+ ardia.

II.1 PRO-NOSIS

ubia

II.11 FO%%O+ )P

For general examination' !atient is %a,ing unstable blood !ressure. First day'

blood !ressure is -9);) mmg' seond day is -3)*) mmg' t%ird day is -8);)

mmg' and +ourt% and +i+t% day are -

sistoli1 on mitral and trius!id ,al,e' gallo! =5>. ?%ile abdomen examination' li,er is

!al!able 3 +ingers under arus ostae and lo0er extremity got minimal edema. 2ut in

+i,e days a+ter admission' t%e !atient %as been losed o+ edema !retibial.

&%e t%era!y +or t%is !atient is still t%e same +rom t%e +irst day admitted to t%e

%os!ital until +i+t% day o+ admission. For !lanning' regularly eletrolite examination.

-3


12/15

CHAPTER III

CASE ANA%$SIS

$n t%is ase'a man' 63 years old' residenes at Palembang ity' 0as

admitted to dr. Mo%ammad oesin %os!ital sine Otober (nd' ())*.

Patient ame 0it% %ie+ om!lain s%ortness o+ breat% so %ea,y sine -

day be+ore admitted to %os!ital. From t%e %istory o+ illness' about -) days be+ore

admission' t%e !atient om!lained o+ %a,ing s%ortness o+ breat%' it 0as de!end on

!osition' !atient +ell more om+ortable i+ %e sit do0n' and de!end on ati,ity' %e 0ill

s%ortness o+ breat% a+ter go to toilet' !atient 0ould not om!lained it i+ %e 0as ta1e a

rest. 2ut no de!end on 0eat%er and not +ollo0ing o+ ngi1 ,oie. e 0ill be more

om+ortable 0it% ( 4 3 !illo0s 0%en slee! time. e denies any om!laint 0a1e u! in

slee! time 0it% s%ortness o+ breat% and %est !ain. e also denies any om!laint o+

%eart !al!itation' oug%' +e,er' or o,er s0eating during nig%t time. e also 0as

om!laint edema in bot% o+ lo0er extremity. Bdematous in !al!ebra su!erior 0as

denied. e 0as om!laint iteri in s1in and eyes. e %as no om!laint nausea and

,omitting. &%ere 0as disorder in urinate' turn yello0 tea urine' but no disorder in

de+eation.

/ - day be+ore admission' t%e !atient om!lained o+ %a,ing s%ortness o+

breat% so %ea,y' it 0as de!end on !osition' !atient +ell more om+ortable i+ %e sit

do0n' and de!end on ati,ity' !atient 0ould not om!lained it i+ %e 0as ta1e a rest.

-8


13/15


14/15

=,al,ular endoarditis> or o+ t%e %eart musle =myoarditis>' ongenital %eart disease

=ardia onditions !resent sine birt%>' se,ere lung disease =e.g.' !ulmonary

%y!ertension> or obstruti,e slee! a!nea' !eriardial disease =!eriarditis> and et.;

From general examination' blood !ressure -9)*) mmg' !ulse rate *)

timesminute' reguler' res!iration rate (* timesminute' and tem!erature 36'9 ) C. On

t%e measuring o+ body %eig%t -9* m and body 0eig%t 9* 1g' t%is !atient is

o,ernutrition.

From t%e !%ysial examination' t%ere 0as an inreasing ugular ,ein

!ressure =9D(> m(O. $nreasing o+ JEP is mean t%at t%ere 0ere rig%t side o+ %eart

+ailure-). ugular ,ein !ressure is +reuently assessed as a mar1er o+ +luid status'

0%i% an be aentuated by t%e %e!atougular re+lux. On !ulmonal examination' so+t0et rales on t%e base le+t and rig%t !ulmo. $n %eart examination' itus ordis an be

seen and !al!able at $CS E' %eart is enlarged 0it% u!!er boundary is $CS $$$' le+t

boundary is "AA sinistra and rig%t boundary is "MC dextra. ?it% ausultation' t%ere

0as sistoli murmur on mitral and trius!id ,al,e. Sistoli murmur is es!eial sign o+

mitral insu+isiensi. Magni+iation o+ %eart is om!ensation o+ ongesti,e o+ %eart

+ailure*. $n abdomen examination' li,er 0as !al!able 3 +ingers under arus ostae. $t

mean t%at t%ere 0ere signi+iant li,er ongestion may result in im!aired li,er

+untion' and 0e an loo1 at eyes examination' t%ere 0as slera iteri. Ot%er' 0e got

minimal edema !retibial' it ause exess +luid aumulation in t%e body.

On additional examination' +rom laboratory +indings' t%ere 0ere

dereasing %emoglobin =--'; gdl>' %ematorite =39 ,ol>' tromboyte =-)-.)))mm

> and lo0 " =(3 mgdl> and dereasing !otassium =3'3 mmoll>. BS# and di++

ount is normally' it mean t%at no %roni disease. 2SS measure is su!!osed to 1no0

0%et%er t%is !atient %as diabetes mellitus or not' beause !atient 0it% diabetes

mellitus an be ause o+ ongesti,e %eart +ailure' but in t%is !atient' 2SS is -3( mgdl

0%i% s%o0 t%at %is blood gluose is normal. Patient 0it% edema 0ill be ta1e diureti'

so eletrolite rate must be 1no0n and 0at%. $n t%is !atient' sodium is normal =-39

mmoll> but !otassium 0as derease =3'3 mmoll>' so t%at 0e must be 0at%.

-6
http://en.wikipedia.org/wiki/Abdominojugular_testhttp://en.wikipedia.org/wiki/Abdominojugular_test


15/15

On radiologial +inding s%o0s t%ere 0as magniti+iation o+ or' to rig%t

and to le+t' !ulmo s%o0 ranialisation and also Kerley line. Kerley line means t%ere

0as edema intersitial 0%i% es!eial sign +or edema !ulmonal and t%ere 0as in

radiologial mitral stenosis. On eletroardiogra!%y' AF dan axis 0as normal' # @

*; timesminute' P 0a,e inestimable' I#S om!lex@ )')* seonds' #S E- -' SE-

D #E9E6 39' I !at% E3 4 E9' im!ressi,e AF D OM$ lateral. AF ondition

detetable in mitral insu+isiensi and also I !at% an be got in mitral insu+isiensi

aused by is%emi.

From anamnesis' !%ysial examination' and also additional examination'

it an be onluded 0or1ing diagnosis ongesti,e %eart +ailure et ausa mitral

insu+isiensi 4 mitral stenosis D %y!ertension stage $' 0%i% di++erentiated diagnose0it% ongesti,e %eart +ailure et ausa %y!ertension %eart disease D %y!ertension stage

$ and ongesti,e %eart +ailure et ausa oronary %eart disease D %y!ertension stage $.

&reatment +or t%is !atient are bedrest' or diet $E' %al+ sitted !osition +or

non!%arma%ology' $EF 9 gtt minutemiro' +urosemide am! -x-' a!to!ril tab

3x(9 mg' s!ironolatone tab -x(9 mg' aetosal tab -x-)) mg' ome!raGole tab -x-'

laxadyn syr 3x-C and KS# -x- +or !%arma%ology. Prognosis +or ongesti,e %eart

+ailure determined by ardia status-). +or t%is !atient' 0e ust !rognosis dubia at t%e

same time 0e +ollo0 u! %is ardia status.

-

Case Bareng Iyem

Documents

Transcript of Case Bareng Iyem