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Patient Identity
Name Age Gender Religion Occupation Address Medical Record Hospitalized : Mr. S : 79 years old : Male : Moslem :: Manahan Banjarsari : 01189086 : April 9th 2013
CHIEF COMPLAINT
Shortness of breath
EATING BEHAVIOR
2-3 times a day, consumed rice, vegetables, tahu-tempe, occassionally eggs ang meat.
LIFE STYLE
SOSIOECONOMIC
He is an unemployment with 4 children and 5 grandchildren. His wife was dead 2 years ago. He lives with his son. His son works as a labour.
PHYSICAL EXAMINATION
General Condition: Compos Mentis, moderate illness Vital Signs: BP = 135/80 mmHg HR = 87 bpm, reguler, normal intensity RR = 20 times/minute Temperature = 36,2C (axillar) Nutritional status = normoweight
Eyes
: Pale conjunctiva (-/-), Icteric conjunctiva (-/-) Neck : JVP wasnt increased, No enlargement of Lymphnode Thorax : normochest, symmetrical, intercostal retractions (-)
Heart : - Inspection : Ictus cordis was seen at SIC VI Linea Axilaris Anterior Sinistra - Palpation : Ictus cordis wast - Percussion : 1. Upper limit of the right heart: SIC II, linea parasternalis dextra 2. Bottom right cardiac border: SIC IV, linea parasternalis dextra 3. Upper left cardiac border: SIC II, linea parasternalis sinistra 4. Lower left cardiac border: SIC VI, linea axilaris anterior sinistra Impression: cardiac border was extend caudolateral - Auscultation: 1. Heart Rate: 87 x/ min, regular 2. Intensity of the Heart sound I-II are normal, regular, murmurs (-), Gallop (+)
Lungs : Front Inspection : static and dynamic symmetric Palpation : fumbling fremitus for right = left Percussion : sonor/ sonor Auscultation : Basic vesicular sounds (+/+), Fine crackles (-/-), rales (+/+) in lower third of the lungs , wheezing (-/-) Back Inspection : static and dynamic symmetric Palpation : fumbling fremitus for right = left Percussion : sonor / sonor Auscultation: basic vesicular sound (+/+), fine crackles (-/-), rales (+/+) in lower third of the lungs , wheezing (-/-)
Abdominal : - Inspection : abdominal wall = chest wall - Auscultation : bowel peristaltic (+) normal - Percussion : tympanic - Palpation : outgoing, tenderness (-), liver and spleen not palpable, epigastric pain (+) Back : Kyphosis (-), lordosis (-), scoliosis (-) Extremity : - Above : pitting edema (-/-), cold acral (-/-), wound (-/-), clubbing finger (-/-), spoon nail (-/-) - Under : pitting edema (-/-), cold acral (-/-), wound (-/-), clubbing finger (-/-), spoon nail (-/-)
09/4/2013 Hb HCT RBC WBC PLT GDS Ureum Creatinin Natrium Kalium Chlorida CKMB Troponin 11,9 36 3,72 5,0 217 100 81 1,2 138 4,2 113 7,8 0,02
mmol/L
mmol/L mmol/L ng/l ug/l
Sinus Rhythm, HR 82 bpm Left Axis Deviation Left Atrial Enlargement T inverted in lead I, aVL, V5, V6
Simetric Bronchovascular system is normal Costophrenic angle is blunt CTR >50 % Calsification of aortic knob Fibroinfiltrat with multiple cavities in right lung Cephalitation in both of lungs
CONCLUSION Cardiomegaly with aorto schlerosis Early suspect of oedem pulmo Suspect of TB Bilateral efussion of pleura
Anatomic : anteroseptal OMI Functional : Decompensated cordis NYHA IV Etiology : hipertension heart disease Comorbid : dyspepsia
Half-sitting bedrest O2 3lt/mnt Infus RL 10 dpm Furosemid Inj 20 mg/8 hours Ranitidin Inj. 50 mg/12 hours Spironolakton 25 mg 1-0-0 ISDN 3 x 5 mg Captopril 3x12,5 mg Simvastatin 20 mg 0-0-1 Alprazolam 0,5 mg 0-0-1 Aspilet 80 mg 0-1-0 Antacyd syr 3 x CI
PROGNOSIS
Ad Vitam : dubia ad bonam Ad Sanam : dubia ad malam Ad funsionam : dubia ad malam