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MR Kardio 22-9-2019

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Morning Report
Monday, Sep 22th 2019
Deni
Reis
Lia
Mario
Hendry
Aulia
Okto
Amel
Name
Age
Address
MR
Date of Admission
DPJP
: Mrs. S
: 68 years old
: Makassar
: 894830
: Sep 22th, 2019
: dr. AFM
The patient was referred from Siwa Hospital
with Acute Decompensated Heart Failure
History Taking
A 68 y.o woman was admitted with Shortness of breath
It was felt since 3 days before admission, aggravated by activity. DOE (+),
PND (+) Ortopneu (+). Cough (-). No previous history of SOB and
palpitation. There was no chest pain.
History of hypertension (+) since 1 year ago, not taking routine medication.
History of diabetes mellitus (-)
History of cardiovascular disease (-)
At the referred hospital, she was treated with furosemide 20 mg iv, aspilet
80 mg oral, amlodipin 10 mg oral, ranitidine iv, ceftriaxone iv, paracetamol
500 mg oral.
Physical Examination
• BP: 170/100 mmHg, HR : 83 bpm regular, RR :
26 tpm, T: 36.70C, O2 saturation 99%
• Conjunctiva not anemic, sclera not icteric
• JVP R+3 cmH2O
• Vesicular breath sound, rales (+) basal
bilateral, wheezing (-)
• Regular heart sound, murmur (-)
• Abdomen: Peristaltic (+) H/L not palpable
• Extremity: warm, no oedema
ECG (22/09/2019) SIWA ER
10.00
Sinus Rhythm, HR 71x/min, axis 80o, PR interval 0,16 s, QRS duration 0,16 s with rSR’ at V1-2
Conclusion: sinus rhythm, Heart Rate 71x/min, short PR interval, normoaxis, complete RBBB
ECG (22/09/2019) PJT ER
18.20
Sinus Rhythm, HR 71x/min, axis 80o, PR interval 0,16 s, QRS duration 0,16 s with rSR’ at V1-2
Conclusion: sinus rhythm, Heart Rate 71x/min, short PR interval, normoaxis, complete RBBB
Lab. Findings (22/09/2019)
WBC
5.3
103/mm3
4-10 x 103/mm3
N/L/M/E/B
67.8/17.9/10.9/2.8/0.6
%
HGB
12.7
g/dl
14-18
PLT
260
103/mm3
150-400 x 103/mm3
SGOT
17
U/L
< 38
SGPT
10
U/L
< 41
Ureum
36
mg/dl
10-50
Creatinin
0.84
mg/dl
<1,3
PT
10.0
s
10 – 14
aPTT
25.5
s
22.0 – 30.0
INR
0.96
Sodium
141
mmol/l
136 – 145
Potassium
3.9
mmol/l
3.5 – 5.1
chloride
100
mmol/l
97 – 111
RBG
123
Mg/dl
140
-
Chest Xray (22/09/2019)
• Haziness at suprahilar and
paracardial both of lung
• Cor enlarged with CTI 0,69
concave cardiac waist
• Dilatation and elongation
aortae
• Bone intact
• Soft tissue normal
Conclusion :
• Cardiomegaly with sign of lung
oedema
• Dilatation and elongation
aortae
Echocardiography (22/09/2019)
• Preserved LV systolic function, EF 59.4% by TEICH, EF 59.5% (BIPLANE)
• Cardiac chamber dimension : normal condition (LVEDd 4,96 cm, LVEDs 3.39 cm, LA mayor 4.9 cm,
LA minor 4.4 cm, RA mayor 3.7 cm, RA minor 2.4 cm, RVDB 2.2 cm)
• Aor diameter 3,1 cm, LA 2,7 cm LA/Ao 0,8 cm
• Left Ventricular Hypertrophy: concentric positive (LVMI 132 g/m2, RWT 0,52)
• Myocard movement: Global normokinetic
• Preserved RV systolic function, TAPSE 2.0 cm
• Valves :
o Mitral
: Good normal and fuction
o Aorta
: 3 cuspis, Calcification (+) RCC, AR Mild (AR PHT 610 ms)
o Tricuspid
: Good normal and fuction
o Pulmonal
: Good normal and fuction
o E/A <1, eRAP 3 mmHg (IVC ekspirasi 1,0 cm/inspirasi 0,3 cm)
o LVSV 80 ml, LVCO 4,6 l/min , SVR 2088 dynes/cm5/sec
Conclusion :
Preserved LV and RV systolic function, EF 59,5% (Biplane)
Concentric LVH
AR Mild
Mild degree diastolic dysfunction
Working Diagnosis
• CONGESTIVE HEART FAILURE NYHA III
• HIPERTENSIVE HEART DISEASE
Management
Nitroglycerin 10 mcg/minute/syringe pump
Furosemide 40mg/12 hours/intravenous
Captopril 25 mg/8 hours/oral
Plan
- Transfer to ward
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