ADVISOR:

Dr. M. SAUGI A, Sp.PD

Presented BY:
ANIS KHOIROTUN NISA’
01.207.5443
Name : Mrs. K
Age : 66 yo
Gender : Female
Religion : Islam
Job : jobless
Address : Tlogosari kulon, Semarang
MR number : 116.39.50
Room : Baitul izzah
Check in date : 6/3/2012
Check Out date : 10/3/2012
Patient came to RSISA with dyspneu for about 1 month
as a major complain. She also complained that she was
get palpitation, headache, and more sweat.
± a week before hospitalized patient also complained
that she couldn’t sleep at that night due to those pain.
Patient usually felt palpitation when she was get more
activity.
c ) History Advance Disease:
 Previously have been sick like this, patient was
hospitalized 3 times.
 Hypertension history (-)
 Astma history (-)
 Heart disease (-)
 Hypertention (-)
 Asma (-)

 Hospitalized cost was certified by her

family
 Economic impression : capable
General : dyspneu (+)
Skin : itching (-), jaundice (-), pale (-), slick (-)
Head : headache (+)
Eyes : blurred vision (-), red eyes (-)
Ears : hearing loss (-), discharge (-)
Nose : nosebleed (-), discharge (-)
Mouth : thrush (-), bleeding gums (-)
Throat : swallowing pain(-), hoarseness (-)
Neck : enlargement of the gland (-)
Chest : cough (-), sputum (-), blood (-)
Cardiac : chest pain (-), palpitations (+)
Digestive : appetite (+), nausea (-), vomiting (-),
defecation / micsion (+/+),
Musculoskeletal : weak (-), rigid (-), tremor (-)
Extremity : oedem low extremity (-)
 General Status
◦ General : dyspneu (+)
◦ Awareness : composmentis
◦ Nutrient Status
Height = 170 cm
Weight = 70 kg
BMI = BB(kg)/TB²(m²)
= 70 kg/(1,7 m)²
= 70/2,89
= 24,22 (Normoweight)
 Vital Sign
o Blood Pressure : 110/60 mmHg
o Heart rate :73x/minutes, irreguler, adequate amplitudo, same
equality, elastic artery wall, pulsus alternans (-), pulsus
defisit (+)
o Breath : 24x/minutes
o Temp : 36,6o C
 Head : Mesocephal, alopesia (-)
 Eyes : Anemic Conjuntival (-/-), Icteric sclera(-/-)
 Nose : symmetric, secret (-), Nostril Breath (-)
 Ears : Normal Shape, discharge (-/-)
 Throat : Hyperemic (-), pain devour (-)
 Mouth : Cyanosis (-), dry lips (-),
 Neck : Trakhea deviation (-), Lymph Hypertropy (-)
 Extremity : Oedem of lower extremity (-), Oedem of upper extremity (-)
 Dyspneu
 HR irreguler , pulsus defisit
INSPEKSI ANTERIOR POSTERIOR
Static RR : 24x/min, Hyperpigmentation (- RR : 24x/min, Hiperpigmentasi
), spider nevi (-), atrofi M. Pectoralis (-), spider nevi (-), Hemithoraks
(-), Hemithoraks D=S, ICS Normal, D=S, ICS Normal, Diameter AP <
Diameter AP < LL LL
Dinamic Up and down of hemitoraks D=S, Up and down of hemitoraks D=S,
abdominothorakal breathing, (-), abdominothorakal breathing (-),
muscle retraction of breathing (-), muscle retraction of breathing (-
retraction ICS (-) ), retraction ICS (-)
Palpation Palpation pain (-), tumor (-), Arcus Palpation pain (-), tumor (-),
costae angle < 900, enlargemnet of Stem fremitus D=S
ICS (-), Stem fremitus D=S
Percution Sonor sonor
Auskultati Vesicular sound, ronchi (-), wheezing Vesicular sound, ronchi (-),
on (-) wheezing (-)
INSPECTION Ictus cordis isn’t seen at ICS V linea midclavicula
PALPATION Ictus cordis is palpable at ICS VI ± 2cm to lateral from mid clavicula
sin line, thrill (-), pulsus epigastrium (-), pulsus parasternal (-),
sternal lift (-)
PERCUTION dull sound
Upper borderline of heart : ICS II linea sternalis sinistra
Waist of heart : ICS III 1 cm lateral of linea
para sternalis sinistra
Lower right borderline of heart : ICS VI linea sternalis dextraLower
left borderline of heart : ICS VI ± 2cm to lateral from mid
clavicula
sinistra line
AUSCULTATI aorta valve : S1 and S2 standart, additional sound (-), AI<A2
ONI pulmonal valve : S1 and S2 standart, additional sound (-), P1<P2
trikuspidal valve : S1 and S2 standart, additional sound (-) T1>T2
Mitral valve : S1 and S2 standart, additional sound (-) , M1>M2
HR : 73 x/menit, irreguler

Interpretation : suspect cardiomegali

INSPEKSISimetris, sycatric (-), striae (-), enlargement of vena (-), caput
medusa (-), frog like abdoment (-), slick (-)
AUSKULT bowl peristaltic (+) N, bruit (-), renalis artery buzzing (-),
ASI abdominal aortic buzzing(-), Iliaka artery buzzing (-), femoralis
artery buzzing (-)
PERKUSI Timpani on the all of abdomen, side of deaf (-), shifting dullness
(-), undulasi (-)
 Hepar : deaf (+)
Liver span dextra 11 cm di linea midclavicularis dextra, liver
span sinistra 8 cm di linea midsternalis
 Hepatomegali (-)
 Lien : troube space percusion timpani
 Splenomegali (-)
PALPASI Superfisial
 Supel, Massa (-), abdominal pain (-), defence muscular (-)
Dalam
 Abdominal pain (-), hepar and lien aren’t palpable, Murphy’s
sign (-)

Interpretation : normal
Ekstremitas superior inferior
- oedem -/- -/-
- akral dingin -/- -/-
- reflek fisiologis +/+ +/+
- ikterik -/- -/-
Tgl 7/03/2012
 Rhythm : irreguler
 HR Frequency : 9 x 10 = 90
 AXIS : in lead I = Positif
aVF = Positif
 (Normo Axis Deviation)
 Transition zone : V4
 P wave : 0,12 seconds, and sometime no P wave
 PR interval : 0,20
 QRS complex : 0,12
 ST segment : normal
 Gelombang T : There’s no T inverted
 Other : VES
 Interpretation :
 VES bigemini
 Atrial fibrilation
Tgl 9/03/2012
 Rhythm : irreguler
 HR Frequency : 7 x 10 = 70
 AXIS : in lead I = Positif
aVF = Positif
 (Normo Axis Deviation)
 Transition zone : V4
 P wave : 0,12 seconds, and sometimes no P waves
 PR interval : 0,20
 QRS complex : 0,12
 ST segment : normal
 Gelombang T : There’s no T inverted
 Other : VES
 Interpretation :
 VES frequent
 Atrial fibrilation
Tgl 10/03/2012
 Rhythm : irreguler
 HR Frequency : 9 x 10 = 90
 AXIS : in lead I = Positif
aVF = Positif
 (Normo Axis Deviation)
 Transition zone : V4
 P wave : 0,12 seconds, and sometimes no P waves
 PR interval : 0,20
 QRS complex : 0,12
 ST segment : normal
 Gelombang T : There’s no T inverted
 Other : VES
 Interpretation :
 VES frequent
 Atrial fibrilation
 Cardiomegali
 Elongation aorta
 Routine Hematology Analytical blood chemistry Electrolyte
Hb 11,4 Cholesterol 126 Natrium 143
Kalium 4,3
Ht 34,1 Trigliserid 122
Chloride 114
Leucocyte 5,04 HDL 17
Erytrocyte 4,02 LDL 96

Platelet 387 Uric Acid 6,0

LED 1 104
LED 2 109 Imunoserology
Blood O (+) HBsAg negative
Group

Interprtation :
normal
 Anamnesa Physical Advance
 Dyspneu Examination Examination
 headache  Dyspneu  VES frequent
 palpitation  HR irreguler ,
 Atrial fibrilation
pulsus defisit
 Cardiomegali
 Elongation aorta
 CHF
 Atrial fibrilation
 VES frequent (aritmia)
 Ass : Anatomi diagnosis(LVH,RVH)
Etiology Diagnosis (Hipertension heart disease,
kardiomipati)
 IP Dx : Echocardiography
 Ip Tx :
 Non Farmacology
 Bed rest
 ½ of sit down position
 Farmacology
 O2 2-3 L/minutes
 Digoxin (1 x ½ tab) (25mg)
 Furosemid 1 / 12 hour (diuretic)
 KSR 2x 1
 Captopril 2x 6,25 mg
 Spinorolacton 1 x 25 mg
 laxative drugs
 Ip Mx :
 Vital sign, Fluid Balanced, Electrolit lab, electrocardiograpy
 Ip Ex :
 Explain about the disease
 Maintain weight
 Avoid drink and eat too much
 Reduce salt intake and Avoid alcohol and cigarette
 Mild Exercise at least 30 minute in everyday
 Consumption drug regularly
 Routine check of blood pressure.
 Ass : -
 IP.dx : -
IP.tx : - aspirin 1 x 80 mg
- Digoxin 2 x ½

 IpMx : vital sign, EKG

 IP.EX :
 Explain about the disease
 Consumption drug regularly
 Routine check
 Ass : -
 IP.dx : -
 IP.tx : - Bisoprolol 1 x 5mg
 IpMx : vital sign, EKG
 IP.EX :
 Explain about the disease
 avoidance of aggravating factors (eg, stress, caffeine-
containing products)
 Routine check