Case report

Advisor: dr. Riki Tenggara, Sp.Pd-KGEH

Presented by:
VINCENTIUS/ 2017-060-10140
Nadia Octaviany/ 2017-060-10166
Identity
• Name : Mr. K
• Age : 46 years
• Adress : Muara Baru
• Occupation : Seller
• Marital status : Married
• Religion : Islam
• Date of admission : 29th January 2019
• Tanggal periksa : 29th January 2019
History
Chief complaint : Shortness of breath since 2 days before
admission
Additional complaints : Nausea and loss of appetite
History of Present Illness
He was admitted to the Atma Jaya Hospital because of shortness
of breath since 2 days before admission. He got tired quickly after he
was doing his activities. The shortness of breath occurred 1 year ago for
the first time and intermittent. The shortness of breath was felt
especially when he was in recumbent position. Sometimes, he was
awakened by the shortness of breath while he was sleeping. He also
complained about loss of appetite since 2 days before admission, he
couldn’t eat because he felt nausea.
History
History of past illness:
• He was diagnosed with a heart disease and he always checks up
routinely

History of family illness:

• Denied
History
Personal history:
• He often eats unhealthy foods (eg. Fats)
• Drinking habit was denied
• Smoking was denied

History of drug use :

• The patient routinely takes Furosemide
Physical examinations
• General appearance : Moderately ill
• Consciousness : Compos Mentis (E4M6V5)
• Vital signs :
Blood pressure : 110/70 mmHg
Pulse rate : 133x/minutes, irregular.
Respiratory rate : 20x/minutes
Temperature : 36,6 oC
• Head : deformity (-), symmetry
• Eyes : Anemic conjunctiva -/-, icteric sclera -/-, pupils 3 mm/ 3 mm,
isochoric, DLR +/+, ILR +/+
• Ears : Deformity -/-, secrete -/-
Physical Examinations
• Nose : Deformity -, secrete -/-

• Neck : No trachea deviation, JVP 5+3 cmH2O, Lymph node enlargement -,

Tumor -
• Mulut :
Lips : Pallor
Oral mucosa : wet
Tongue : Coated tongue (-)
Pharynx : Hyperemic (-)
Tonsils : T1/T1
Physical Examinations
• Thorax:
• Heart:
• Inspection : The apical impulse was not visible
• Palpation : The apical impulse was not palpable
• Percussion : Upper border of the heart was in 3rd ICS
Right border of the heart was in 4th ICS right parasternal line
Left border of the heart was in 5th ICS midclavicular line
• Auscultation : 1st and 2nd heart sounds were regular, murmur -, gallop -

• Lungs:
• Inspection : Symmetrical respiratory movements, retractions -
• Palpation : Symmetrical tactile fremitus, symmetrical respiratory movements
• Percussion : Resonance +/+, Hepatic Lung Border ICS V, peranjakan 1 ICS
• Auscultation : Vesicular +/+, wheezing -/-, rhonchi -/-
Physical Examinations
• Abdomen :
• Inspection : Flat, scar (-)
• Auscultation : Bowel sound (+), 6x/minute
• Palpation : Abdominal tenderness -
• Percussion : timpani in all abdominal region
• Back :
• Alignment : Within normal limit
• CVA tenderness : (-/-)
• Extremities
• Icteric (-)
• CRT < 2 s
• Warm
• Edema -/-/-/-
Physical Examinations
• Neurologic examinations
• Physiologic reflex
• Biceps : ++/++
• Triceps : ++/++
• Patella : ++/++
• Achilles : ++/++
• Pathological reflex : -/-
• Motoric : Within normal limits
• Sensoric : Within normal limits
Working Diagnosis
• Congestive heart failure
Laboratory Examination
• Hb : 15 g/ dL
• Hematocrit : 48%
• Erythrocyte : 7.200.000
• Leukocyte : 7000 / mm3
• Platelet : 150.000 / mm3
• Diff count : 0/2/1/62/30/5
• LED : 26 mm/ hour
Urinalysis
• Macroscopic:
- Color : yellow
- Clear
- Specific gravity : 1.010
• Protein :-
• Glucose :-
• Bilirubin : -
• Microscopic :
- Erythrocyte :-
- Leukocyte :-
- Cylinder :-
- Epithelial :-
Feces Examinations
• Microscopic:
- Epithelial: -
- Macrophage: -
- Leukocyte: -
- Erythrocyte: -
- Food residue: -
- Parasite: -
- Ova: -
 Laboratory Examination
(29/01/19)
Examination Result Normal Range

Hb 15.3 12 – 15.8 g/dL

Ht 48 35,4-44,4 %

Leukocyte 6570 3,540 – 9,060 /uL

Erythrocyte 7.47 4,0 – 5,2 juta/uL

Platelet 146 165-415 /uL

 Examinatons Results Normal Range

MCV 63.9 79 – 93.3 fl

MCH 20.5 26.7 – 31.9 pg

MCHC 32.1 32.3 – 35.9 fl

Electrocardiogram
Resume
• Mr. K, 41 years old, admitted to the Atma Jaya Hospital with a
dyspnea on effort since 2 days before admission. He also has
paroxysmal nocturnal dyspnea and orthopnea. He also complained
about loss of appetite since 2 days before admission and felt nausea.
• On the physical examinations, there were found: the general
appearance was moderately ill, compos mentis, tachycardia,
arrhythmia, increase of JVP, cardiomegaly, increase of hematocrit and
erythrocyte. Urinalysis and Feces examinations are within normal
limits.
Diagnosis Kerja
• CHF NYHA III-IV
• AF-RVR
Recommendation of Examination
• Echocardiography
Therapy
• O2 3 lpm by nasal canule
• Bisoprolol 1x5 mg PO
• Furosemide 2x40 mg PO
THANK YOU