Case Presentation

A 55 Years Man with

Dyspnea
By:
Valentina Lakhsmi
G99141003
Advisor :
Prof. Dr. dr. Mochammad Fathoni,
SpJP(K), FIHA, FAsCC, FAPSC

Patient Identity

Name
: Mr. SYD
Age
: 55 years old
Sex
: Male
Address : Wonogiri
Job
: driver
Date of entry : 22 July 2014
Date of inspection : 23 July 2014
Medical Record Number: 00 75 43 20

Chief Complain

ANAMNESIS

Present

History of Patient Ilness

History of patient disease

STROKE

Physical Examination
(22/07/2014)
General condition

Anamnesis
Px Fisik
Eye:
pale conjunctiva
(-/-),

icteric sclera (-/-)

Neck: JVP elevated

Abdomen: liver and

spleen were not palpable,
bowel sound (+) normal,
ballotement (-)

oedem (-/-)
Cold extremities (-/-)
Hemiparese dx

Px Penunjang

Cor:
Resume

Diagnosis

I: Ictus Cordis was not

visible
P: Ictus cordis was not
palpable
P: cardiac border dilated
caudolateral
A: heart sound I-II normal
intensity, regular, murmur
(-)

Pulmo: vesicular breath

sound (+/+), rales (+/+),
crackles (-/-), wheezing (-/-)
oedem (+/+)
Cold extremities (-/-)
Hemiparese dx

Emergency Room 22/07/2014 (11.47 am)

sinus tachycardia
106 bpm
LAD, LVH
Pathologic Q waves
in V1-V5

ER

Laboratory Findings
(22/07/2014)

HB
: 16,6
HCT : 47
AL
: 11,5
AT
: 305
AE
: 5,51
MCV : 85,6
MCH : 30,1
MCHC: 35,2
RDW : 12,5
MPV : 8,7
PDW : 16

GDS
: 274
SGOT
: 62
SGPT
: 150
Creatinine : 2,4
Ureum
: 104
Na
: 138
K
: 5,2
Cl
: 109
HbsAg: nonreactive
Albumin : 3,8

Laboratory Findings
(22/07/2014)
BGA
pH
: 7.316
BE
: -7.9
pCO2
: 33.8
pO2
: 118.5
H2CO3
: 18.0
Total CO2: 14.0
SaO2
: 98.0
Uncompensated metabolic acidocis

Echocardiography
(03/05/2012)

Excentric LVH with

restrictive diastolic
disturbance
Abnormality of
segmental wall
motion (EF : 25%)
MR and TR mild

Diagnose
Azotemiacordis
Decomp
ec
AKIFC
dd
NYHA
Acute IV
on CKD
coronary
artery
disease
Hyperkalemia
Hemiparesis

Therapy
(22/07/2014)

Total
Cardiac
O2
IVFD
Aspilet
Inj
Simvastatin
Captopril
3 lpm
RL
bedrest
1x80
diet
20
nasal
cc/h
1x20
steam
mg
semi
canul
(wait
mg
Fowler
riceCT
1700
scan
position
kcal
result)

PLAN

Chest X-Ray
Echocardiography
Complete the laboratory tests for DM
Consultation with neurologist
Cranial CT scan
Consultation with internist

Physical Examination
(23/07/2014)
General condition

Anamnesis
Px Fisik
Eye:
pale conjunctiva
(-/-),

icteric sclera (-/-)

Neck: JVP elevated

Abdomen: liver and

spleen were not palpable,
bowel sound (+) normal,
ballotement (-)

oedem (-/-)
Cold extremities (-/-)
Hemiparesis dx

Px Penunjang

Cor:
Resume

Diagnosis

I: Ictus Cordis was not

visible
P: Ictus cordis was not
palpable
P: cardiac border dilated
caudolateral
A: heart sound I-II normal
intensity, regular, murmur
(-)

Pulmo: vesicular breath

sound (+/+), rales (+/+),
crackles (-/-), wheezing (-/-)
oedem (+/+)
Cold extremities (-/-)
Hemiparesis dx

Laboratory Findings
(23/07/2014)

HbA1c
: 8,1
GDP
: 187
GD2PP
: 297
Creatinine : 2,4
Ureum
: 90
Uric acid : 11,7
Total Chol : 252
LDL
: 194
HDL
: 32
Trigliserida : 169

ECG
ICVCU(23/07/2014; 05.00 a.m)

Sinus rhythm 99
bpm
LAD
LVH, LAH, RAH
Pathologic Q
waves in V1-V5

ICVCU (23/07/2014)

Radiology
(23/07/2014)

CTR >50%
cardiomegaly with
pulmonary oedema

Neurologic Findings ( 23/07/2014 )

GCS E4V5M6

Neurologic Findings ( 23/07/2014 )

Diagnose

Therapy
(23/07/2014)

Total
Cardiac
O2
IVFD
Aspilet
Inj
Simvastatin
Captopril
3 lpm
RL
bedrest
1x80
diet
20
nasal
cc/h
1x20
steam
mg
semi
canul
(wait
mg
Fowler
riceCT
1700
scan
position
kcal
result)

PLAN
Echocardiography
Consultation with internist
Cranial CT scan

Case analysis

Case analysis

Case analysis : complication of MI

Case analysis

Case analysis

Thank you