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Gender : Female
Religion : Moslem
Job :-
MR number : 01132348
Main Problem
• Dyspneu
Location : Chest
Static RR : 28x/min, Hyper pigment (-), spider nevi RR : 28x/min, Hyper pigment
(-), atrophy Pectoral Muscle (-), Hemithoraks (-),spider nevi (-), Hemithoraks D=S,
D=S, ICS Normal, Diameter AP < LL ICS Normal, Diameter AP < LL
Palpation Palpable pain(-), tumor (-), Arcus costae Palpable pain (-), tumor (-), Arcus
angle < 900, enlargement of ICS (-), increase costae angle < 900, enlargement of
of Stem fremitus ICS (-), increase Stem fremitus
Auskultation Vesicular (+), Whezzing (-), Ronchi (+) Vesicular (+), Whezzing (-), Intepretation :
Ronchi (-) Takipneu,
oedem pulmo
CARDIAC EXAMINATION
Inspection : Ictus cordis isnt seen.
Intepretation : Cardiomegaly
...CONT
Auscultation
Aortal valve : S1 & S2 standard, additional sound (-)
Intepretation : Normal
ABDOMEN EXAMINATION
Inspection : symetric, sycatric(-), striae(-),enlargement of vena (-),
caputmedusa (-).
Auscultation : peristaltic (+)
Palpation :
• Superfisial : tight (-), mass (-), epigastrial pain (-)
• Deep : abdominal pain (-), liver, kidney, and spleen weren’t
palpable, Murphy’s sign (-)
Percussion : tympani, side of deaf (-), shifting dullness (-)
• Liver : deaf(+), right liver span 11 cm, left liver span 6 cm
• Spleen : Throbe space percussion (+) tympani
Intepretation : Normal
EXTREMITY EXAMINATION
Ekstremitas Superior Inferior
• Pitting
Oedema -/- +/+
• Cold -/- -/-
• Jaundice -/- -/-
HEMATOLOGY KIMIA
Hemoglobin 10.0 (L) 13.2 - 17.3 g/dl Gula Darah 129 (H) 75 - 110 mg/dl
Sewaktu
Hematokrit 29.1 (L) 33 - 45 % Ureum 154 (H) 10 - 50 mg/dl
Leukosit 7.37 3.8 – 10.6 ribu/uL Creatinin Darah 5.39 (H) 0.7 – 1.3 mg/dl
Trombosit 191 150 - 440 ribu/uL Natrium 130.5 (L) 135 - 147 mmol/L
X-Foto Thorax
COR = apeks ke laterokaudal.
Elongasi arcus aorta
Pulmo = carakan vaskuler tak
meningkat. Tak tampak gambaran
infiltrat
Diafragma sisi kanan tampak
scalloping.
Sinus kostofrenikus kanan kiri lancip
Interpretation =
Cardiomegaly (LV)
Elongasi arcus aorta
Pulmo tak tampak gambaran infiltrat
ECG 19/9/2019 , 10.10 pm
Interpretation
Rhytm : Sinus
Regularity : Regular
Frequency : 70 x/menit
Axis : lead 1 = +; AvF = - LAD
Transition zone : V2
P wave : 0,08 s (normal)
PR Interval : 0,20 s (normal)
QRS Interval : 0,08 s (normal)
Pathologic Q wave : + di lead II, III, aVF
ST Segment : elevated ST (-), depressed ST (-)
T wave : Inverted T di lead V4, V5, V6
ECHO Dinding LV :
Menebal di PW
Wall Motion :
Global Hipokinetik
Katup jantung : AR
Mild TR Mild MR
Mild
Fungsi LV Sistolik
Menurun EF 38%
Fungsi RV Sistolik Baik
TAPSE 17 mm
Fungsi LV Diastolik baik
E/A > 1
Interpretation:
Global Hipokinetik
Decrease of
sistolic LV function
Fungsi RV Sistolik
baik
Hipertropi PW
AR Mild TR Mild MR
Mid
Abnormal Data
Chest X-Ray:
both extremities
Problem List
CHF
1. Orthopneu IHD
2. Swelling extremities Azotemia 1. Ischemic inferior from
3. Increasing JVP
1. Ureum : 296 mg/dl (H) ECG
4. Oedem Pulmo
2. creatinin : 5, 30mg/dl 2. Decrease of sistolic LV
5. Cardiomegaly from PF
function
6. Oedema of both extremities
7. Chest X-Ray Cardiomegaly
Ass :
Anatomi : LVH
Fungsional : NYHA III
Etiologi : IHD, HHD
IP Dx : BNP (≥ 35 pg/mL) dan Pro-BNP (≥ 125 pg/mL), angiography coroner
IP Tx :
Pharmacology
oInfus RL 20 tpm
oInjeksi Furosemide 2x1 amp (20mg/2mL)
oBisoprolol 2,5mg po 1x1
oARB
Non Pharmacology
IP Ex :
Bed Rest/Restriction of physical activity
Sodium & Fluid restriction
Reducing Emotional stress
Sit position or a half sleep position
Ischemic Heart Disease
Ass: Etiologi : Unstabel Angina
IP Tx :
Non Pharmacology
Aspilet 1 x 80 mg (maintenance)
CPG 1 x 75 mg (maintenance)
Ip.Mx : ECG
Ip.Ex :
IP Dx : -
IP Tx :
Natrium correction 0,6 x 50 x (140 - 134,2) = 174 mEq/L
NaCl 0,9 % 1 flabot 1 flabot NaCl 0,9 % : Na 154 meq/L ; Cl 154 meq/L
IP Mx
Natrium status post correction, General state, Awareness, ECG, Vital Sign,
IP Ex
Explain about disease
Explain about treatment and side effect
Hiperkalemi
Assassemen :-
IP Dx : -
IP Tx : Hemodialysis, dietary restriction
Farmakologi : sodium bicarbonat to exchange K+ extra vaskular to
intravaskular
, ca glukonas, insulin combine with dextrose 10%. to prevent aritmia
Restin to binding K+ perifer
IP Mx
kalium status, General state, Awareness, ECG, Vital Sign,
IP Ex
Explain about disease
Explain about treatment and side effect
Hiperglikemi
Assassemen : DM & non DM
IP Dx : GDP, GD2PP, TTGO
IP Tx :
Non Pharmacology :
Lifestyle management
Medical nutrition theraphy
Exercise
IP Mx : Blood glucose
IP Ex :
Explain to patient about the condition, and complication that may occur
Controlling dietary habits
Reduce glucose intake
Exercise
Assassement : CKD
Azotemia IP Dx : USG Kidney
IP Tx :
Non pharmacologic :
Limitation of protein intake (0.6-0.8/kgBB/day),
Calorie Intake 30-35 kkal/kgBB/day
Dialysis
Pharmacologic :
CaCO3 3x1
Asam folat
Bicarbonat (prevent metabolic asidosis)
IP Mx
Vital Sign,GFR, uremic sign, general state, awareness, fluid
balance, ureum creatinin level
IP Ex
Explain to the patient about the disease
Explain about dialysis
Take medicine regularly
Explain side effect of medication
Explain about proper daily intake, including type of diet and food
Routine Control of Blood Pressure
TEORI
CHF
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HIPONATREMI
HIPERKALEMI
Summary
UA NSTEMI AMI