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Case Based Discussion: Gagal Jantung Dan TB Paru
Case Based Discussion: Gagal Jantung Dan TB Paru
Case Based Discussion: Gagal Jantung Dan TB Paru
Oleh :
Fitri Aulia Ananda
012116397
Pembimbing :
dr. Lusito, Sp.PD
A. PATIENT IDENTITY
Name
: Mr. H
Age
: 50 y.o
Sex
: Male
Religion
: Moslem
Job
: Swasta
: 01264481
Address
Room Care
: Baitul Izzah 2
Date in
: 26 Sept 2015
Date out
: 7 Okt 2015
Status Care
B. CHRONOLOGY
When the date was 26th of September 2015 , Patient came to Internist Clinic
Sultan Agung Hospital with tightness. He complained feel tightness while
walking . Patients come about to check up on her illness. Approximately one
week already complained of this. He also should wake up at night besause of
cough and tightness. He had cough with thick phlegm since 3 weeks. He had been
given the drug from the stall, but not cured. His weight decreased approximately
for one month.
C. ANAMNESIS
General
: weak
Skin
Head
: headache (-)
Eyes
Ears
Nose
Mouth
Throat
Neck
Chest
Cardiac
Digestive
Musculosceletal
Extremity
D. PHYSICAL EXAMINATION
a. VITAL SIGN
i. BP = 130/80 mmHg
ii. HR = 84 x/menit
iii. RR = 28 x/menit
iv. T
= 36,5 0C
b. BMI
i. BB = 48 Kg
ii. TB = 160 cm
iii. BMI = 18,7 (Normal)
c. THORAX
INSPEKSI
ANTERIOR
POSTERIOR
Static
Dinamic
Palpation
Percussion
Dextra: sonor
Sinistra : redup
Dextra: sonor
Sinistra : redup
Auscultation
d. CARDIAC
i. Inspection : Ictus cordis can t be seen.
ii. Palpation : Ictus cordis is palpable at SIC V linea mid
clavicula sinistra, thrill (-), pulsus
epigastrium (-), pulsus para-sternal (-), sternal lift (-).
iii. Percussion : dull sound
1. Upper borderline of heart
: SIC III linea sternalis
sinistra
2. Waist of heart
: SIC IV linea
parasternalis sinistra
superior
inferior
- Oedem
-/-
-/-
- cold extremities
-/-
-/-
- Icteric
-/-
-/-
E. LABORATORY EXAMINATION
examination
result
result
Hb
12,6 g/dl
Ht
36.3 %
Leukosit
10,9 ribu/uL
Trombosit
342 ribu/uL
Mikrobiologi
BTA (Sputum)
2+
F. ECG
Irama : sinus
Regularitas : reguler
Frekuensi : 100 x/ menit
Axis : LAD
Zona Transisi V6 ( clockwise)
Gel P : 0,06 s
QRS : 0,12 , S persisten di V5
Segmen ST : isoelektris
Gel T : T inverted di V1 dan V2
Kesan : LAD , Iskemi lateral kanan, LVH
G. RADIOLOGY
H. DATA ABNORMALITIES
Anamnesis :
1. Dispneu
2. Weak
3. Headache
4. Cough
5. Loss weight
Physical Examination:
6. Percusion in cor : cardiomegali
7. Auscustation ronkhi
Advance Examination:
8. BTA = 2+
9. Radiology : CTR > 50% Cardiomegaly
10. Radiology Bronchovasulary imaging
I. PROBLEM LIST
J. CHF
Ass
: IHD,LVH, LAH
IP Dx
IP Tx
:
Non pharmacology
Low Salt intake
Reduce activity
High fiber Diet
Pharmacology
Infus RL 10 tpm
Nasal O2 3lt/minute
Captopril 2x12,5mg
Spironolakton 1 x 25 mg
Bisoprolol 1x2,5mg
Digoxin 0,25 mg (2x1)