Cardiology Department

Medical Faculty
Hasanuddin University

Case Report

NUR SYAFAWATI HALIM

C 111 11 875
Supervisor:

dr.Yulius Patimang, SpA, SpJP, FIHA

HASANUDDIN UNIVERSITY
MAKASSAR
2016

Patient Identity

Name
Age
Gender
Address
MR

:
:
:
:
:

Ny. S
46 years old
Female
Jl. G. Bawakaraeng
747028

History Taking

Chief complain : Shortness of breath

It was felt since 7 months ago and worsen 2 weeks

before admitted to the hospital. Shortness of breath felt
continuously and worsens during any mild exertion.
Shortness of breath is not influenced by weather.
Now patient slept using 3 pillows or with sitting position.
Sometimes awaked during at night time that caused by
sudden shortness of breath. He fatigues easily.
Chest pain (+) when shortness of breath without
spreading to left side , there is no history of chest pain.
Heartburn (+), cough (+) without sputum.
He has not experienced fever, headache, nausea and
vomiting. Micturition and defecation is normal.
Oedema extremities (+)

Past Medical History

History of hypertension (+) since 1

year ago ; not controlled
History of diabetes mellitus (-)
History of family members with same
illness (-)
History of getting treatment in
hospital for the same repeating
complaints (-)

Physical
Examination
General state:

Moderate Illness/ Well

nourished/Composmentis

Vital sign
Blood Pressure
Heart Rate

: 180/100 mmHg
: 110 x/mnt
Respiratory Rate : 26 x/mnt
Body Temperature: 36,7 C

Physical
Examination

Head and Neck

Eye
Lip
Neck

: Conjunctiva anemic (+/+), Sclera icteric (-/-)

: Cyanosis (-)
: JVP R +3 cmHO

Thorax
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: Respiratory sound: Vesicular
Additional sound :Ronchi mediobasal +/+, Wheezing -/-

Physical Examination

Cor
Inspection : Apex was not visible
Palpation
: Apex was not palpable
Percussion : Right heart border in right

parasternal line, left heart

border in left
midclavicular line ICS V
Auscultation
: Heart sound: SI/II
regular,

Physical Examination

Abdomen
Inspection
: Flat, follows breathing movement
Auscultation : Peristaltic sound (+), normal
Palpation
: No mass, no tenderness, liver
and spleen unpalpable
Percussion
: Tympani (+)

Extremities examination
Pretibial edema +/+
Dorsum pedis edema -/-

ELECTROCARDIOGRA
M (ECG)

ECG interpretation
Irama: sinus rhythm
QRS rate: 115 bpm
Axis: normo axis
P wave: normal
QRS complex: 0,12
s, S V1 + R V5 <
35 mm
ST segment :
:
ST depresi at II, III,
AVF
T Wave : inverted
Summary
Sinus takikardi,
HR 115x/i,
Normoaxis ,

CHEST X-RAY
Result:
Cardiomegaly

et dilatatio aorta with

sign of lungs congestion.

ECHOCARDIOGR
AM
Result:

Dysfunction

systolic of LV ,
Ejection Fraction 37%
Dilatation at whole chambers.
Dilatation at aortae
Left Ventrikel Hipertrofi
ecsentrik
Global hipokinetic
MR mild
AR severe,TR severe
PH severe
Dysfunction dyastolic of
LV GradeIII

LABORATORY TEST
PEMERIKSAAN

NILAI RUJUKAN

UNIT

WBC

4.00-10.00

103/ul

RBC

4.00-6.00

106/ul

HB

12.0-16.0

gr/dl

Plt

150-400

103/ul

PT

10-14

Detik

22.0-33.0

Detik

APTT

NILAI

INR

--

GDS

140

mg/dl

10-50

mg/dl

L(<1.3) P(<1.1)

mg/dl

SGOT

<38

U/L

SGPT

<41

U/L

Natrium

136-145

mmol/l

Kalium

3.5-5.1

mmol/l

Klorida

97-111

mmol/l

Ureum
Creatinin

DIAGNOSIS

CHF NYHA III ec CAD

Hypertenion stage II
DM type 2

THERAPY

O2 4 lpm via nasal canule

Fluid restriction
IVFD NaCl 0,9% 500 cc/24 h
Captopril 25mg/24h/oral
Simvastatin 20mg/24h/oral
Furosemide 40mg/24h/oral
Farsorbid 10mg/8h/oral
Aspilet 80mg/24h/oral
Levemir 0-0-12 IU/SC
Novorapid 6-6-6 IU/SC

Prognosis

Poor prognosis
3040% of patients die within 1 year of
diagnosis and 6070% die within 5 years,
mainly from worsening HF or as a sudden
event (probably because of a ventricular
arrhythmia)
Patients with symptoms at rest (NYHA
class IV) have a 3070% annual mortality
rate, whereas patients with symptoms
with moderate activity (NYHA class II)
have an annual mortality rate of 510%

Thank You