CHF ec CADANDLYMPHADENITIS TB Prajnya Paramitha N

030.08.192

Identity

Name : Mr. S Age : 71 yo Gender : Men Adress : Bojong, Karawang Occupation : Unemployed Religion : Islam Marital status : Married Race : Sundanese Education : Senior high school

Admission to hospital on 16th of October 2012

ANAMNESE

Autoanamnese on 18th of October 2012 at 10.30

History of present disease A 71-year-old male presented to RSUD Karawang with a one-

week history of shortness of breath. The symptom occurs especially during activities such as walking and having daily meals. Patient also complaint of waking up from sleeping due to breathlessness that occurs a few hours after lying down but relieves after he sits, therefore he needs 5 pillows during his sleep. Patient felt palpitation occasionally and denied of having hacking cough with pinkish froth.

Patient complained of swellings on all of his extremities since one week before being admitted to the hospital in which making him unable to walk and have difficulties to move his extremities freely. His scrotum has also been swollen for 2 days. Due to this swellings, patient complained of a rapid weight gain around 5kgs in 10 days or less.

History of present disease• He also felt fatigue since 10 days ago. • He declared of having productive cough for

approximately 20 days with mucous phlegm in a range of colors from white to green which is hard to be coughed out.

• Defecation was normal. Urination was normal• There were no complaints of chest pain, fever, decrease

of appetite, difficulty nor pain in swallowing, tension headache, bloating stomach, nor decrease of consciousness.

History of past disease

Family history

No one in his family has a symptom or disease like him Hypertension (-), Dyspepsia (-), Liver disease (-), Kidney

disease (-), Cancer (-), Diabetes Mellitus (-)

Drinks coffee 4 cups a day Smokes 5 cigarettes a day Eats rice, vegetables, and tempe Drinks plenty of water up to 8 glasses a day Drugs (-), Tatoo (-), Alcohol (-)

Habitual history

PHYSICAL EXAMINATION

General condition

THORAX HEART

Inspection : Symmetrical Palpation : Equal vocal resonancePercussion : Sonor in both lungsAuscultation : Vesicular breath sound in both

lung,ronchi (+/+),wheezing (-/-)

THORAXLUNG

INSPECTION Brown skin, symmetrical, supple,

flat Icteric (-), Caput medusae (-),

spider nevi (-)

AUSCULTATION Bowel sound (+) , venous hum (-),

arterial bruit (-)

PERCUSSION Tympani Shifting dullnes (-)

PALPATION Turgor N Tenderness (-) Hepatomegali (+), splenomegali (-) Hepatojugular reflex (+)

ABDOMEN

Warm acral

Edema

Wet

Deformity (-), brown skin , spider nevi (-), palmar erythema (-), pale (-), icteric (-), flapping tremor (-), swelling on all extremities, CRT < 2secs

EXTREMITY

Haematology Result Normal

Hemoglobin 11,5 12-17 gr/dL

Leukocytes 32.400 5.000 – 10.000

Trombocytes 443.000 150.000 – 450.000

Hematocrite 34 37-43%

Ureum 42 10-45 mg/dl

Creatinin 1,23 0.4-1.5 mg/dl

SGOT 28 <40/ul

SGPT 18 <40/ul

LABORATORY

CXR

ECG

RESUME

DIFFERENTIAL DIAGNOSIS

• CHF ec CAD • CHF ec Cardiomyopathy• CHF ec RHD • CHF ec HHD• COPD

Treatments• Pharmacology

• KAEN 3B + Furosemid 2 amp• Tab Aldacton e1x12,5mg• Tab Thrombo Aspilet 1x80mg• Tab Clopidogrel 1x75mg• Tab Captopril 3x25gram• Tab Alprazolam 1x0,5mg• Tab Ambroxol 3x1• Tab sublingual ISDN 3x2,5mg• Caps Hepamax 3x1• Tab ATP Dancos 2x1• Tab Rifampycin 450mg 1x1• Tab Pyrazinamid 500mg 3x2• Tab Pulna 1x3

• Non pharmacology• HCHP diet, low sodium diet• Education

Suggested examination

• Echocardiography • BNP• Acid-fast bacillus smear

• Sputum• Fine-needle

aspiration biopsy• Surgical excision

biopsy• Blood gas analysis• Electrolyte

Prognosis

• Ad Vitam : Dubia ad Malam• Ad Fungtionam : Dubia ad Malam• Ad Sanationam : Dubia ad Malam