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
