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Department of Cardiology and Vascular Medicine Medical Faculty of Hasanuddin University Makassar 2013
Medical Record : 64-24-44 Name : Mr. AH Gender : Male Age : 68 years old Admininistered date: December 18th, 2013
It was felt since 1 year before entering the hospital and getting worse in 1 day before admission. It was experienced while doing minimal activity such as walking to the bathroom and relieved with rest. Shortness of breath when sleep (+) patient used 2 pillows and often awakened because of that. Shortness of breath is also accompanied by pain in the middle of the chest, duration > 30 minutes, characterized with being pressured through the back, and radiating to the left arm and neck, and got lessen with rest. Palpitation (+), cold sweat (+), nausea (), vomiting (-), heartburn (-), fever (-), cough (-). Defecation : normal Urinary : normal
History of admission with the same complaint (+) 1 year ago without regular treatment History of hypertension (+) since 3 years ago without regular treatment History of diabetes mellitus ( - ) History of family with same disease ( - )
Modifiable
- Cigarette Smoking - Hypertension
Unmodifiable
- Gender : Man - Age : 68 y.o - Past heart disease
General Status Moderate Ilness/Well nourished/Conscious Body Weight :53 kg Body Height :165 cm Body Mass Index : 19,62 kg/m2 Vital Signs BP : 140/80mmHg HR : 90 bpm, regular RR : 26 bpm T : 36,5C
Chest Examination
Inspection: Symmetric between left and right chest. Palpation : No mass, no tenderness. Percussion : Sonor between left and right chest, lungliver border in ICS IV right anterior . Auscultation : Breath Sounds : Vesicular - Adventitious breath sound : Ronchi + /+ , wheezing -/-
Heart Examination o Inspection : IC was visible o Palpation : IC was palpable o Percussion : normal heart size Upper border : left 2nd ICS Lower border : left 6th ICS Right border : right parasternalis line Left border : left anterior axillaris line o Auscultation : Regular of I/II heart sound, murmur (-) Abdominal Examination o Inspection : flat and following breath movement o Auscultation : peristaltic sound (+) , normal o Palpation : liver and spleen unpalpable o Percussion : tympani, ascites (-) Extremities o Oedema
HEMATOLOGY
VALUE
REFERENCE VALUE
UNIT
PLT
GDS Ureum Creatinin
241
175
150-400
140 10-50 <1,3
(103/uL)
Mg/dL Mg/dL Mg/dL
23
0,9
22 54 200 66 109 67
CK
CKMB Troponin T Natrium Kalium Chloride
79
42 0,20 119 4,2 94
L(<190),P(<167)
<25 <0,05 136-145 3,5-5,1 97-111
U/L
U/L --mmol mmol mmol
Rhythm : Sinus Heart rate : 88 bpm Regularity : Reguler Axis : RAD P wave : 0,05 s PR interval : 0,16 s QRS complex : 0,1 s ST Segment : Normal, S wave widening in lead I and V6 T wave : Conclusion : Sinus rhythm, HR 88x/m, Right axis deviation, incomplete RBBB
Decreased of systolic LV function, EF 30% Dimensional chambers of heart : dilatation of LV & LA, SEC (-), thrombus (-) LVH (+) Global hypokinetic Good RV systolic function, TAPSE 2,0 cm Heart valves : - Aorta : 3 cuspis, calcification - Tricuspid : good function and movement - Pulmonal : good function and movement
Conclusion : LV systolic and diastolic disfunction, EF 30% Dilatation of LV & LA Global hypokinetic
Bed rest Oxygen 2-4 lpm via nasal canul IVFD NaCl 0,9% 500 cc/24 hours Diuretic Furosemide 20 mg/ 12 hours/iv ACE-I Captopril 3x12,5mg Nitrat Fasorbid (oral) 3x10 mg
Anti Platelet Aspirin 1x 80 mg Clopidogrel 1x 75 mg Anti Coagulant Heparin 600 IU/ hour/ sp Anti Cholesterol Simvastatin 1 x 20 mg Traguilizer Alprazolam 1 x 0,5 mg Laxans Laxadyne syrup 1 x 2 S
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 The state in which abnormal circulatory congestion occurs as the result of heart failure.
Other Causes Arrhythmias Valvular heart disease Congenital heart disease Pericardial disease Hyperdynamic circulation Alcohol and drugs(chemotherapy)
Cardiomyopathy(dilated)
(30-40%)
Hypertension ( 15-20%)
Major Criteria
Paroxysmal Nocturnal Dyspnea Cardiomegaly Gallop S3 Hepatojugular reflux Increased of JVP Rales or ronchi Acute pulmonary edema Prolonged circulation time(> 25 sec) Weigh loss 4,5 kg in 5 days in response to treatment of CHF
Minor Criteria
Extremity edema Nocturnal cough Decreased vital pulmonary capacity (1/3 of maximal) Hepatomegaly Pleural effusion Tachycardia ( 120bpm) Dyspnea deffort
Coronary artery disease (CAD) is a narrowing or blockage of the arteries and vessels that provide oxygen and nutrients to the heart. It is caused by atherosclerosis, an accumulation of fatty materials on the inner linings of arteries. The resulting blockage restricts blood flow to the heart.
CAD
ACS
UAP
NSTEMI
STEMI
Substernal chest pain / chest discomfort radiated to the left arm, shoulder, neck, jaw. Penetrated to the back. The chest discomfort may also be described as a dull pain, pressure, squeezing or crushing sensation or burning sensation Duration more than 20 minutes. More intense and persistent. Not fully relieved by rest or nitroglycerine Often accompanied by systemic symptoms: nausea, vomiting, palpitation, fatigue, cold sweat, light headness