Download - Chf Dr. Arif Done
![Page 1: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/1.jpg)
Dini Noviani Pratiwi030.08.084
MEDICAL FACULTY OF TRISAKTI UNIVERSITY
RSUD KARAWANG
![Page 2: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/2.jpg)
Name : Mrs. TSex : FemaleAge : 59 yoAddress : Dongkal II 13/02 PedisOccupation : HousewifeReligion : MoeslimRace : SundaneseEducation : Elementary schoolMarital Status : MarriedDate of admission : 16th july 2012Taken from : Rengas Dengklok
Ward
IDENTITY
![Page 3: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/3.jpg)
CLINICAL HISTORYCLINICAL HISTORY
CHIEF COMPLAINT : Shortness of breath since about 10 days before hospitalized.
ADDITIONAL COMPLAINT
Abdominal Pain
nausea
Vomit
Swelling in the both feet Cough
![Page 4: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/4.jpg)
HISTORY OF PRESENT ILLNESSHISTORY OF PRESENT ILLNESS
The patient came to Emergency Unit of Karawang Hospital with complaint of shortness of breath since 10 days before hospitalized. The symptom felt worsening and appeared when she is in rush and during her normal activities such as sweeping . The symptom appeared when she lies flat on her back, and because of it she’s using 2 - 3 pillows when sleeping. She always suddenly woken up when she is sleeping because of breathlessness.
She also complained of having both feet swelling a week before admission, esp at night. The swelling getting worse from day to day. She also complaint pain in the right upper stomach . The breathlessness is not affected by cold, dust, or emotion, and no wheezing. She denied having a chest pain, fever, but suffered a bit of nausea and vomit.
![Page 5: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/5.jpg)
She also complaining dizziness since 1 day before hospitalized. The dizziness is getting worse since the onset but getting better when she take a rest. She also complaining cough with phlegm, blood is negative.
Miction was about 7-8 times/day. Urine color was yellow. Defecation was normal.
HISTORY OF PRESENT ILLNESSHISTORY OF PRESENT ILLNESS
![Page 6: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/6.jpg)
![Page 7: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/7.jpg)
HISTORY OF PAST ILLNESSHISTORY OF PAST ILLNESS
- Gastritis- Hypertension since 5 Years ago
- Gastritis- Hypertension since 5 Years ago
- Diabetes Melitus- Allergy- Cardiovascular disease- Kidney disease- Asthma
- Diabetes Melitus- Allergy- Cardiovascular disease- Kidney disease- Asthma
![Page 8: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/8.jpg)
History of Family Illness
Cardivaskular disease (-) Asthma (-) Hypertension (-) Allergy (-) DM (-)
Personal and Social History
• Smoking (-)• Alcohol (-)
• Exercise regularly (-) • Consume Ht drugs not regularly
![Page 9: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/9.jpg)
VITAL SIGNVITAL SIGN
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
General appearance ; Moderately ill
Consciousness ; COMPOS MENTIS
![Page 10: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/10.jpg)
PHYSICAL EXAMINATION
Head:NormocephaliAnemic conjunctiva -/-, Icteric sclera -/-Cyanotic lip (-)
Neck:Thyroid gland & lymph nodes enlargement are not palpableTrachea located in the middleJVP : (5+4) cmH2O
![Page 11: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/11.jpg)
PE ( HEART )
I : Ictus cordis is visible at 6th ICS 3 cm lat LMCSPal : Ictus cordis is palpable at 6th ICS 3 cm lat LMCSPer : Upper R : 3rd ics, LSD
Upper L : 3rd ics, LPS Bottom R : 5th ics, LSD Bottom L : 6th ics, 3 cm lat LMCS
A : S1-2 regular murmur (+) loudest at mitral area, gallop (-)
![Page 12: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/12.jpg)
PE ( LUNG )
Inspection : Symmetrical in static and dynamic,
intercostals retraction (-)
Palpation : Equal vocal resonance, the breath
movement symmetricPercussion : Sonor in both lungsAuscultation : Vesicular, Ronchi (+/+) at base both lungs,
Wheezing (-/-)
![Page 13: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/13.jpg)
PE ( ABDOMEN )
Inspection: Brown skin & bloated abdomen, smiling umbilicus (-),vein dilatation (-), lesion (-), scars (-), striae (-)
Auscultation :Peristaltic sound (+) normal (3 times in 1 minute)
Palpation: Turgor normal, muscular defense (-), mass (-), hepar and lien enlargement (-), ballotement (-/-)
Percussion: Tympanic, no pain present on abdominal pecussionShifting dullness (-)
![Page 14: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/14.jpg)
Warm acrals
Edema
EXTREMITY EXAMINATION
![Page 15: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/15.jpg)
RESULT NORMAL
HemoglobinLeukocyteTrombocyteHtEritrosit
14.99.400
174.00046.84.68
12 – 17 g%5000 – 10000150 – 450ribu
37 – 48 %3.8 – 5.8 jt/mm2
GDSUreumCreatininSGOTSGPT
10644,71,433011
80 – 140 mg/dl10 – 45 mg/dl0.4 – 1.5 mg/dl
<40 u/l<40 u/l
LABORATORIUMLABORATORIUM
![Page 16: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/16.jpg)
RADIOLOGYRADIOLOGY
F : Thorax PA
D : CTR > 50%- Enlargement of
Left Ventricle (LVH)- Enlargement of Right Ventricle (RVH)-Enlargement of Left Atrium (LAH)- Right costophrenicus angle is blunt
![Page 17: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/17.jpg)
ELECTROCARDIOGRAPHY
![Page 18: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/18.jpg)
Ax-Shortness of breath
Dispnoe on effortPNDOrtopnea
- Abdominal pain- Swelling of both feet- Nausea- Vomit- Cough- Hypertension since 5 Years ago
Ax-Shortness of breath
Dispnoe on effortPNDOrtopnea
- Abdominal pain- Swelling of both feet- Nausea- Vomit- Cough- Hypertension since 5 Years ago
Ro - CTR : >50% --> Cardiomegaly- LVH- LAH-RVH-Right CP angle blunt
Ro - CTR : >50% --> Cardiomegaly- LVH- LAH-RVH-Right CP angle blunt
PE- VT: TD : 170/100mmHg RR : 32X/M- JVP : 5+4 cmh2O- Ronchi (+/+) - Murmur (+) - Edema in both feet
PE- VT: TD : 170/100mmHg RR : 32X/M- JVP : 5+4 cmh2O- Ronchi (+/+) - Murmur (+) - Edema in both feet
RESUMERESUME
![Page 19: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/19.jpg)
DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
![Page 20: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/20.jpg)
WORKING DIAGNOSISWORKING DIAGNOSIS
CHF NYHA II e.c HHD with Pleural Effusion DextraCHF NYHA II e.c HHD with Pleural Effusion Dextra
![Page 21: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/21.jpg)
PROFIL LIPID
URINALYSIS
ECHOCARDIOGRAM
CARDIAC ENZYME MARKER
PROFIL LIPID
URINALYSIS
ECHOCARDIOGRAM
CARDIAC ENZYME MARKER
SUGGESTED EXAMINATIONSUGGESTED EXAMINATION
![Page 22: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/22.jpg)
• Total bed rest• O2 2-4L/m• Low salt diet• IVFD D5% 20tpm• Lasix 2 x 1 amp• Ceftriaxone 1 x 2gr• Acran 2 x 1 amp• Ambroxol syr 3 x CI• Captopril 2x 12,5mg
• Total bed rest• O2 2-4L/m• Low salt diet• IVFD D5% 20tpm• Lasix 2 x 1 amp• Ceftriaxone 1 x 2gr• Acran 2 x 1 amp• Ambroxol syr 3 x CI• Captopril 2x 12,5mg
TREATMENT
![Page 23: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/23.jpg)
PROGNOSIS
Bonam
![Page 24: Chf Dr. Arif Done](https://reader036.vdocuments.us/reader036/viewer/2022070301/545ef6f9af79593a708b4a9b/html5/thumbnails/24.jpg)
Thank You