Case report

Dept. of internal medicine

G24
Identity
 Name : Mrs. K
 Age : 54 years old
 Occupation : IRT
 Address : Deket Lamongan
 Admission: July 13 th, 2016 at 19.01
 Chief Complaint

Sesak
 Present history

Pasien mengeluh sesak sejak 3 hari yang lalu, mengeluhkan

bengkak pada kedua kaki hingga perut sejak 2 minggu smrs. Mual
-, muntah -, BAB BAK dalam batas normal. Warna BAK kadang
seperti teh. Batuk + kadang-kadang. Tidur menggunakan 3 bantal,
sering bangun pada malam hari karena sesak +, sesak saat
beraktifitas dan membaik ketika beristirahat
 Past history of Illness

•Riwayat penyakit jantung +, DM-, HT-

 Family history

No familial related
 Social history

No social history related

Vital Signs
 BP
 124/96 mmHg
 Pulse
 130 x/min, strong, reguler
 Temp
 36.5 0 C
 RR
 40 x/min
 A: clear, gargling (-), snoring (-), speak fluently (+),
potential obstruction (-)
 B: spontan, RR 40x/min, ves (weak) / ves, rh -/-, wh -/-,
SaO2 100% without O2 support
 C: extremity WDR, CRT <2’, N 130x/min, BP 124/96
mmHg
 D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
 E: temp 36.5 C
GENERAL STATUS
 General condition : weak
 Awareness : compos mentis
 GCS : 456
 H/N : a -/i+/c-/d-
lymph node enlargement at neck (-)
JVP within normal limit
 Thorax
 Inspection
 Symmetrical, retraction -
 Palpation
 Thrill (-), fremitus WNL
 Percussion
 Lungs: sonor / sonor
 Cor: N
 Auscultation
 Lungs: ves /ves, rh +/+, wh -/-
 Cor: S1S2 single, M -, gallop -
 Abdomen
 Inspection
 Cembung
 Auscultation
 Met -, bowel sound WNL
 Palpation
 Liver/Spleen within normal limit, Nyeri tekan regio hipokondrium
sinistra dan lumbal sinistra
 Percussion
 Tymphany
 Extremities
 Inspection
 Clubbing fingers (-), icteric (+), cyanosis (-), edema (-)
 Palpation
 Warm and dry, CRT <2’
CLUE AND CUE
 Male, 50 years old
 Hiccup
Planning Diagnose
Rontgen thorax
DL
ECG
Assesment
 Decompensatio cordis
 ALO
 Laboratory Findings

 Eritrosit 3.90  Monosit 7.5

 Hb 10.1  Neutropil 77.3
 Trombosit 214
 Limposit 10.2
 SGOT 23
 Basofil 1.5  SGPT 15
 Eosinopil 3.5  Urea 52
 Hematokrit 31.8  Serum creatinin 1.3
 Albumin 2.5
 Leukosit 9.9
 Kalium 3.9
 MCH 25.90  Natrium 134
 MCV 81.50  PO2 72.4
 MCHC 31.80  PCO2 22.1
 pH 7.514
Foto thorax
EKG
Re-Assesment
 Anemia
 Alkalosis
 Electrolyte imbalance
 Hypoalbuminemia
 Decompensatio cordis
 ALO
 Planning Therapy
Inf. Asering 500cc/24 jam
Inj. Ranitidin 2x50 mg
Inj. Furosemide 2 amp  pump furosemide 5mg/jam
P.O digoxin tab 1x1
Asa tab 1x100 mg
Captopril tab 3x6.25mg
PLANNING MONITORING
 Vital Signs
 Patient’s complaint
 Adverse effect
PLANNING EDUCATION
 Explain to the patient and his family about the disease, cause,
complication, intervention of the therapy and prognosis.