Laporan Kasus Dr. Riki.pptx

Case report Advisor: dr. Riki Tenggara, Sp.Pd-KGEH Presented by: VINCENTIUS/ 2017-060-10140 Nadia Octaviany/ 2017-060-10166

Identity • Name • Age • Adress • Occupation • Marital status • Religion • Date of admission • Tanggal periksa

: Mr. K : 46 years : Muara Baru : Seller : Married : Islam : 29th January 2019 : 29th January 2019

History Chief complaint Additional complaints

: Shortness of breath since 2 days before admission : 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 Oral mucosa Tongue Pharynx Tonsils

: Pallor : wet : Coated tongue (-) : Hyperemic (-) : T1/T1

Physical Examinations • Thorax: • Heart:

• Inspection • Palpation • Percussion • Auscultation

: The apical impulse was not visible : The apical impulse was not palpable : 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 : 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

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