SUMMARY OF DATA BASE

Male/ 34yo/CVCU
Chief complain : shortness of breath
History taking : heteroanamnesis from his father
Patient was admitted to Saiful Anwar General Hospital because of
shorthess of breath on and off that was felt since 9 months ago, and got
worsening 8 hours prior to admission precipitate with activities and
accompanied with palpitation. SOB appeared persistently when he was
sleeping flat or in a rest position, he awoken at night due to SOB. He
routinely consume digoxin, spironolactone, furosemide, clopidogrel, from
cardiologist since 7 months ago.
He often felt fatigue since youth, he already diagnosed with valvular
heart disease 9 months ago at Lampung hospital then 7 months ago he
moved to Malang and routinely check his condition to cardiologist, he
reffered to Harapan Kita hospital for
schedule on January 22nd 2014

closured defect of

valvular , got

Past Medical History & Medication: he never hospitalized before.

Social history: He works as a farmer. Smoke since youth. Alcohol
consumption Family History: He is 1st children in 3 siblings. No history of heart
disease in his family,
Review of systems: Unremarkable.

Physical examination
BP = 90/40 mmHg (ER)
142/83 mmHg (CVCU) on
drip dobutamine

PR = 221-246 bpm (ER),

187-192 bpm (CVCU)
irregular-irregular,

RR = 42 tpm regular
(ER), 36 tpm (CVCU)
Kussmaul type

General appearance looked severely ill, dyspneu

GCS 456 , BW: 48 kg

Head

normal

Pupil normal

Neck

JVP R + 5 cmH2O 45 degree

Chest

Tax : 36.2C

Heart:

Ictus invisible and palpable at ICS VI 2cm lat MCL Sinistra

Heaves +, apex beat strong pulse irregular
Splitting S2, rumbling murmur mid-diastolic gr 3/VI punctum maximum at apex,
gallop +

Lung:

Crackles in basal lung D/S

Abdomen

liver span 12cm, palpable 2 cm below costae arch

Extremities

normal
Urine Output: 300 cc/6 hour

3.500Natrium
138
136-145 mmol / L
Laboratory
finding
10.000/L

Leukocyte

8.800

Haemoglobine
MCV

15,20
96,20

11,0-16,5 g/dl
80-97

Kalium

5,28

3,5-5,0 mmol / L

MCH

30,60

26,5-33,5

Chlorida

108

98-106 mmol / L

PCV

35.50

35-50%

RBS

122

< 200 mg/dL

Trombocyte

53.000

146.000390.000/L

SGOT

105

11-41U/L

Eo/Ba/Neu/Ly/
Mo

0,6/0,1/70,
4/24,4/4,5

SGPT

92

10-41U/L

Ureum

36,5

10-50 mg/dL

INR

2,07

0,8-1,30

Creatinine

1,72

0,7-1,5 mg/dL

PT/aPTT

24,8/25,8 11.7/26.7 sec

Urinalysis

(dipstick)

SG: 1,010

pH: 5.5

Protein: -

Gluc: -

Keton: -

Urobil:-

Leu: trace

Bacteria: -

Nitrite: -

Bilirubin: -

Ery: -

Laboratory Finding
BGA

With 02 10 lpm NRBM supplementation

15.50 (ER)

21.05 (CVCU)

PH

7.01

7,06

7,35-7,45

PCO2

47,8

35,9

35-45

PO2

34,9

45,1

80-100

HCO3

9,6

9,9

21-28

O2 saturation

42,4%

63,1%

> 95%

Base Excess

-19,5

-19,6

-3 until +3

Conclusion

Severe metabolic acidosis

Severe hypoxemia

Echocardiography result May 2nd 2014

Echocardiography May 2nd 2014

Enlargment left ventricel. EF 47,6%

LVPW and IVS hypokinetic
Mitral valve normal
Aortic valve normal
Pulmonal hypertension +
Conclusion : large ASD II (high flow)and
pulmonal hypertension

ECG December 2nd 2014, 15.50 at ER

ECG December 2nd 2014, 15.50 at ER

Atrial rhythm, Heart rate 109-202 bpm

Frontal Axis
: RAD
Horizontal Axis
: Clockwise rotation
PR interval
: unidentified
QRS complex
: 0.12
QT interval
: 0.28
S lead I, V lead III, T lead III
Conclusion : AF RVR HR 109-202, RVH

ECG December 2nd 2014, 20.15 at

CVCU

ECG December 2nd 2014, 20.15 at CVCU

Atrial rhythm, Heart rate 147-152 bpm

Frontal Axis
: RAD
Horizontal Axis
: Clockwise rotation
PR interval
: unidentified
QRS complex
: 0.12
QT interval
: 0.28
S lead I, V lead III, T lead III
Conclusion : AF RVR HR 147-152, RVH

Chest X-Ray December 2nd 2014

CXR December 2nd 2014

AP position, asymmetric, enough KV, less

inspiration
Soft tissue normal, Bone normal
Trachea in the middlle
Hemidiaphragm right and left covered by cardiac
imaging
Phrenico costalis angle D blunt and S sharp
Pulmo right and left: BVP increased
Cor: site enlarged to right and left side, size CTR
82%, apex embedded, cardiac waist disappear
Conclusion : cardiomegaly (all chamber enlargment)
dd pericardial effusion, right minimal pleural
effusion

CUE AND CLUE

PL

IDx

Male/34 yo/CVCU
SOB
DOE
Orthopneu
PND
Palpitation
Fatigue
RR 36 tpm, HR 187-192
irregulart-irregular
JVP R + 5 cmH20
Ictus invisible and
palpable at ICS VI 2cm
lat MCL Sinistra
Heaves +, apex beat
strong pulse irregular
Splitting S2, rumbling
murmur mid-diastolic gr
3/VI punctum maximum
at apex, gallop +
Rh +/+ basal

1.Cardi
ogenic
shock

1.1 Acute
Decompe
nsated
Heart
Failure dt
Atrial
Septal
defect
Secundu
m

BGA: severe metabolic

acidosis, severe
hypoxemia
ECG: AF RVR HR 187192, RVH
CXR: cardiomegaly, LAE,
edema pulmonum

PDx

PTx

PMo

O210-12 lpm NRBM

Bedrest, Semifowler
position
Fasting first until SOB
subsided, continued
with
Soft diet 1900
Kkal/day, low salt < 2
gram/ day
Total fluid intake
1000cc/24hours
Fluid balance negative
500 cc
Furosemide 40-40-0
mg (iv)
Dobutamine drip 320mcg/kgbw/minutes
Spironolacton 0-25-0
(po) postponed

VS
subj
Urine
output
Fluid
balanc
e
Lipid
profile

Valve replacement if
condition already
stable

P Edu:
Diseas
e,
cause,
progres
sion

CUE AND CLUE

Male/34 yo/CVCU
Palpitation
ECG: AF RVR HR 187192, RVH
Ictus invisible and
palpable at ICS VI 2cm
lat MCL Sinistra
Heaves +, apex beat
strong pulse irregular
Splitting S2, rumbling
murmur mid-diastolic gr
3/VI punctum maximum
at apex, gallop +
Rh +/+ basal

PL
2. AF
RVR
CHA2D
S2VASc
2 HAS
BLED 1

IDx
2.1 due to
no 1
(cardiac
origin)

PDx
Holter
monitor
ing

PTx
Treat underlying
disease
Inj Digoxin 0.5 mg ->
continue with 0.25 mg
IV if still RVR
Changed into oral
Digoxin 1x0.25 mg if
AF NVR
Warfarin 0-0-4 mg
(postponed)
Ablation treatment if
valvular surgery didnt
work out

PMo
VS
Compla
in, INR
P Edu:
Diseas
e,
cause,
progres
sion

CUE AND CLUE

Male/34 yo/CVCU
SOB
DOE
Orthopneu
PND
Palpitation
Fatigue
RR 36 tpm, HR 187-192
irregulart-irregular
JVP R + 5 cmH20
Ictus invisible and
palpable at ICS VI 2cm
lat MCL Sinistra
Heaves +, apex beat
strong pulse irregular
Splitting S2, rumbling
murmur mid-diastolic gr
3/VI punctum maximum
at apex, gallop +
Rh +/+ basal
BGA: severe metabolic
acidosis, severe
hypoxemia
ECG: AF RVR HR 187192, RVH
CXR: cardiomegaly, LAE,
edema pulmonum

PL

IDx

3.
3.1 Emboli
Severe
pulmon
Metaboli
al?
c
acidosis

PDx

PTx
O210-12 lpm NRBM
Bedrest, Semifowler
position
Drip bicarbonat

PMo
VS
subj
Bga
serial/4
hours
P Edu:
Diseas
e,
cause,
progres
sion

CUE AND CLUE

PL

IDx

Male/34yo/cvcu
OT/PT 105/92
Liver span 12 cm,
palp 2 cm below
costae arch

4.
Increase
of
transam
inase

3.1
Congestive
Liver
Disease
3.2 Hepatitis
viral
infection

HBsAg,
Treat underlying
Anti
disease
HCV,
USG
abdomen

VS
Complain

Male/34yo/cvcu
Trombocyte 54.000
correction 90.000

5.
Tromboc
ytopeni
a

5.1
Trombocytop
enia
associated
with
cardiovascul
ar disease
5.1.1
overproducti
on of
micoplatelet
s
5.1.2
suppression
of platelet
aggregation

Platelet
aggregat
ion test

VS
Complain

6.

6.1 shock

Male/34/cvcu
Shock cardiogenic

PDx

PTx

Treat underlying
disease

PMo

P Edu:
Disease,
cause,
progressi
on

P Edu:
Disease,
cause,
progressi
on

VS