CASE REPORT (10.

00)
Thirty six year-old female consulted from cardiology department with
chief complain weakness since MVR on April 2017

Chief complain : weakness

History of Illness :
± 2 days before admission, patient feel weak, nausea (+), vomit (-),
shortness of breath (+), coughing (-), blackish stool (-), heart feel
pounding (+), fever (-), lightheadedness (+). Because the condition did
not improve, patient went to Kariadi emergency department. Patient
examined by cardiologist, because suspected massif pericardial
effusion, patient had been consulted to surgery department.

Past History of Illness :

History of congenital heart anomaly (-)
History of Mitral Valve Replacement April 2017 (+)
History of diabetes mellitus (-)
History of hypertension (-)
Physical Examination :

General condition : moderately ill

Awareness : GCS E4M6V5 = 15
Vital signs :
RR = 30 x/mnt (regular, adequate depth of breath)
PR = 135 x /mnt (regular, adequate tone and volume)
BP = 103/68 mmHg
t = 36,5 C (A)
SpO2 = 98%

Head : Mesocephal
Eye : anemic palpebral conjungtive -/-, jaundice sclera -/-
Mouth : dry lips (-)
Neck : JVP increase, trachea on the middle
Thorax : lesion (-)
Lung :
I = Static : right = left hemithorax
Dynamic : right = left hemithorax
Pa = Tactil fremitus right = left
Pe = sonor in the entire lung field
Au = Vesicular vocal sound +/+, additional sound -/-

Heart :
I = IC was not seen
Pa = IC was difficult to assess
Pe = Configuration enlarged
A = Distant heart sound, S1 mechanical sound (+), pansistolic murmur
3/6 on left lateral sternal border, gallop (-)
Abdomen :
I : flat
Pa : supple, tenderness (-), liver edge palpated 6 cm below rib arch
Pe : tympanic, liver dullness (+), flank dullness (+), shifting dullness (-)
A : bowel sound (+) normal

Genital : Women, within normal limit

Extremities :
Superior Inferior
Acral : warm warm
Capp. refill : < 2’’/ < 2’’ < 2’’/< 2”
Swelling :-/- -/-
Laboratory Study : (12.00) RSDK

Hb : 13,6 g/dl (12-15)

Ht : 42,7 % (35-47)
L : 9.300 /ul (3,6-11)
T : 377.000/ul (150-400)
GDS : 99 mg/dl (80-160)
Albumin : 4,1 g/dl (3,4-5,0)
Ur : 54 mg/dl (15-39)
Cr : 1,2 mg/dl (0.6-1.3)
Na : 134 mmol/l (136-145)
K : 5,1 mmol/l (3.5-5.1)
Cl : 97 mmol/l (98-107)
Ca : 2,35 mmol/l (2,12-2,52)
Mg : 1,14 mmol/l (0,74-0,99)
PPT : 21,0/10,3 detik (9,4-11,3)
PTT K : 54,8/34,7 detik (23.4-36.8)
INR : 2,12
Radiology
Thoraks Xray AP (26-11-2017 12.00, RSDK)
Echocardiography (26-11-2017 12.30, RSDK)
Working Diagnosis (12.30)
Massive Pericard Effusion with Cardiac Tamponade
Post MVR (April 2017)

Initial Management (12.30)

IpDx :-
IpTx :
• O2 nasal canule 3 lpm
• NaCl 0,9% 12 dpm
• Pro thoracotomy pericardial window cito
• Cefazolin 1 gr intravenous (1 hr before operation)
IpMx :
General condition, vital sign
IpEx :
Diagnosis, operation plan, prognosis
Operation Report (16.50 – 17.10) :
• Patient lied supine on general anesthesia
• Antisepsis and asepsis operation area
• Made transversal incision on SIC V (left mid clavicula line) + 3 cm
• Identify costae and m.intercostalis, open m.intercostalis and pleura,
pericardium looked tense
• Made 2 control stiches on pericard, incision was done between 2
stiches, came out yellowish liquid from pericard space + 200 cc
• Control bleeding
• Apply thorax tube on SIC VI (left anterior mid clavicula line) toward
cranioposterior 8 cm  fixated with silk 1.0  connect to WSD
machine
• Fixated chest tube to chest wall, performed horizontal mattres suture
whole layer with safil 2.0 with live knot
• Suture operation wound layer by layer
• Operation finished
Post Operation Diagnosis (17.10)
Massive Pericard Effusion with Cardiac Tamponade
Post MVR (April 2017)
Post thoracotomy pericardial window

Initial Management (12.30)

IpDx :-
IpTx :
• O2 nasal canule 3 lpm
• NaCl 0,9% 12 dpm
• Join management with cardiology department
IpMx :
General condition, vital sign, WSD production
IpEx :
Diagnosis, operation finding, prognosis
Follow up H + I
S : (-)
O:
General condition well appearance
Vital signs :
RR = 22 x/mnt (regular, adequate depth of breath)
PR = 96 x /mnt (regular, adequate depth and tone)
BP = 110/70 mmHg
t = 36,5 C (A)
SpO2 = 100%
WSD : 100 cc/24 hrs (serohemoragik), undulation (+), bubble air (-)
Heart :
I = IC was not seen
Pa = IC was hard to asses
Pe = Configuration enlarged
Au = S1 mechanical sound (+), pansistolic murmur 3/6 left lateral sternal border
(+), gallop (-)
A: Stable
P : continued