Cad Lapsus Vale 2

8/9/2019 Cad Lapsus Vale 2

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Case Report

Coronary Artery Disease

Supervisor :

dr. H. Bambang Rudy Utantio, SP. JP. FIHA

By :Valentinne Yuasita

04.70.0234


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Identity

Name : Mr. Dalim

Age : 52 years old

Sex : Male

Occupation : Security (Pension)

Address : Damarsi - Buduran

Marital status : Married

Religion : MoeslemAddmited to hospital : 27 June 2010


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Major Complain

Short of Breath


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Disease History Now

Patient come to ER with complain short of breath. He fell

it after he vomiting last morning. He vomit food and fluidwithout blood. He feel discomfort with his stomach. Buthe didnt have gastric pain history. He didnt eat late.

Actually he fell discomfort with his breath since 7 yearsago. But become worst in six months later. He feels betterwhen sleep at home if he use 3 more pillow, less than thathe feel discomfort with his breath.

He often wake up at night because of his shortness ofbreath. It push him to looking for fresh air, and usually hefeel better after that


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He said that his short breath also come who he walktoo long and heavy activity like work at garden.

His short breath doesnt Induced with dust or coldair.

Perceived shortness no wheezing or grok-grok(ronki)

Hes got chest pain too. It feels in his left chest likeburning and creeping to his back. He cant showingspesificly which is the pain come after he feeldisappointed or angry. And he feel chest pain about

5-10 minutes. This chest pain become better after hisemotion was cooling down.


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Formerly Disease History

Asthma denied TB history denied Allergy history denied DM denied HT (+) : Since 7 years ago, he usually consumt

captopril 25 mg 3 x 1 and furosemide 40mg1 x 1, higher sistole 180.

Decompensatio cordis (+)Patient know the heart become bigger since 6 month ago.

Family Disease

HT (+) DM (-) PsycosocietyEducation : Senior high schoolOccuption : Security (Pension)Marital status : Married, 30 years there children


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Habitual :

Alkohol (-) Coffe (+) he drink coffe over than 2 glass a day

Heavy smookers, he smoke continuously 15

years and he stopped 7 years ago (he smokeover than 3 pack a day).

Exercise (-)

He like salty food


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Nutrition Anamnesa

Food consumption : 3 times dailyAmount : medium

Content of

Carbohydrate : mediumProtein : medium

Fat : large

Fruit : lowVegetable : medium

Weight : decrease


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Physical Examination

General condition : Moderate

Consiousness : Composmentis

Blood pressure : 140/100 mmHg, layposition right arm

Pulse pressure : 98 x/menit, reguler and

strong RR : 26 x.menit

Temperature : 36 C


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Head and Neck

Eyes : Conjuntiva anemis (-/-)

Sclera Icterus (+/+)

Ears : Normal

Nose : Dyspneu (+)

Neck : Vena jugularis distension (-)

Trachea in middle

Thyroid hipertrophy (-)


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Thorax

Lung

Inspection : Simetry shape

Simetry movement

Palpation : Simetry movement

Percussion : Simetry fremitus tactilePain (-)

Auscultation :

Vesiculer : Knock sound (+)Ronchi : (+/+) in the whole auscultation

area of lung (wet ronchi)

Wheezing : (-/-)


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COR Inspection : Ictus cordis (-)

heart pulsation (-) Palpation : Ictus (-)Thrill (-)

Percussion :Sinistra :

Ics II dan III 3 cm PSL SinistraIcs IV 3 cm PSL sinistraIcs V 1 cm MCL SinistraIcs VI 1 cm medial Axilla anterior line sinistraDextra :

Ics II dan III 1 cm PSL DextraIcs IV 2 cm PSL DextraIcs V 3 cm PSL DextraIcs VI 3 cm PSL Dextra


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Auscultation

S1S

2tunggal reguler

S3S

4(-)

Opening snap : (-)

Systolic ejectionclick : (-)

Friction rub : (-)

Mur mur : (+)

Fase : SistolicLocation : 3 Ostia

Aorta Valva

Mitral Valva

Trikuspid Valva

Intensity : III / VIPitch : low

Quality : Rumbling

Moving : moving


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ABDOMEN

Inspection : normal

Palpation : Tonus & turgor (N) Spleen and kidney unpalpable Liver palpable 1 cm under arcus costae Epigastric pain (-)

Percussion :Tympanic sound (+)Auscultation : Peristaltic movement (+)Inguinal Genital Anus (normal)

EXTRIMITAS

Accral warm superior + / +

inferior + / +

Edem superior - / -

inferior - / -


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Thorax PA

Cardiomegali

Like Boot Shoes

CTR : 14 + 7 x 100 = 75%28

Pleura Odema


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CONCLUSION

Rate : 1500 / 15 = 100 x / menit

Rhytm : Sinus, reguler

Axis : LAD

Hipertrophy : Left Ventrikel HipertrophyIschemia : Lateral wall iscemia myocard

Infark : -

Misscellaneus : -


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Laboratory

27 June 2010

Test Result Flag Reference Range (limit 3)

WBC 8,6 K/ulLym 1,7Mid 0,7

Gran 6,3RBC 4,55 M/ulHGB 13,2 g/dlHCT 39,9 %MCV 87,6 fl

MCH 29,0MCHC 33,1 9/dlRDW 14,0 %PLT 210 k/ulMPV 9,4 FL

NormalNormalNormal

NormalNormalNormalNormalNormal

NormalNormalNormalNormalNormal

4,1 10,9 K/ul0,6 4,10,0 1,8

2,0 784,20 6,30 M/ul12,0 18,0 g / dl37,0 51,0 0 %80,0 97,0 fl

26,0 32,0 pq31,0 36,0 9 / dl11,5 14,5 %140 440 K/ul0,0 99,8 FL


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Test Metod Result Reference Range

GDA

BUN

Creatinin

Natrium

KaliumChlorida

SGOT

SGPT

Kinetik UV

Jaffe and

Ise

IseIse

Ast IFCC

Ast IFCC

135

14,5

1,3

144

3,8111

385

294

< 140 mg / dl

6 23 mg / dl

0,7 1,2 mg / dl

137 145 mmol / L

3,6 5,0 mmol / L98 107 mmol / L

< 40 U / L

< 41 U / L


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RESUME

MR Dalim 52 years old come to ER because of his short

breath PND (+), Orthopneu (+) , DOE (+), Chest Pain (+)It feels like burning and creeping to his back .It becomeworst after he feel dissapointed or angry .And he feelchest Pain about 5 10 Minutes. The chest pain becomebetter after his emotion was cooling down.

Medical history:HT(+), DC (+)Physical examination :General condition : moderateConsiousness : composmentisBlood Pressure : 140 / 100 mmHg, lay Position

right armPulse Pressure : 98x / menit , reguler and strongRR : 26x / menitTemperatur : 36oc


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ThoraxLung :Ronchi (+/+) in the whole auscultation are of lung (wet ronchi)

COR Inspection : Ictus cordis (-)

heart pulsation (-) Palpation : Ictus (-)

Thrill (-)

Percussion :SinistraIcs II dan III 3 cm PSL SinistraIcs IV 3 cm psl sinistraIcs V MCL SinistraIcs VI 1 cm medial Axilla anterior line sinistra

DextraIcs II dan III 1 cm PSL DextraIcs IV 2 cm PSL DextraIcs V 3 cm PSL DextraIcs VI 3 cm PSL Dextra


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Auscultation

S1S2 tunggal reg

S3S

4(-)

Opening snap : (-)

Systolic ejectionclick : (-)

Friction rub : (-)

Mur mur : (+)

Fase : SistolicLocation : 3 Ostia

Aorta Valva

Mitral Valva

Trikuspid ValvaIntensity : III / VI

Quality : Rumbling

Moving : moving


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Abdomen :Liver Paipable 1 cm Under arcus

costaeExtrimitas : NormalPhoto Thorax : - Cardiomegali

- Odem pleura

Laboratory :

SGOT 385

SGPT 294 Chlorida 111


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Diagnosa

CardiologyI. Dx of etiology : HT stage I JNC VII

Dx of Anatomy : - cardiomegali

- left Ventrikel hiperthrofi

Dx of Fisiologi : DC Nyha FC III

II.Dx of etiologi : CAD

Dx of Anatomy : lateral wall Ischemia myocard

Dx of Fisiologi : DC Nyha FC III

III. Non cardiology

1. Hiperchloridemia2. Hepatomegali

3. Dyspepsia Syndrome


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Planing Diagnosis

USG Abdomen

Profil Lipid

Bilirubin Direct Bilirubin Total


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Therapy

Non farmacology :

Diit low sodium Diit low fat O

22 lpm nasal

Semi fowler position Urinary cateter

Farma cology : Inf PZ life line Furosemide 40 mg 1 0 0 Bisoprolol 5 mg 1 x 1 Spironolakton 25 mg 1 x 1

Aspilat 100mg 1 x 1 Simvastatin 20mg 0 - 0 - 1 Inj.Ranitidin 2 x 1 Amp Inj. Ondancentron 3 x 1 Amp


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PROGNOSE

DUBOIS AD MALAM

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