Embed Size (px)
DESCRIPTION
cardiology
Citation preview
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 : salesman• Date of entry : 22 July 2014• Date of inspection : 23 July 2014• Medical Record Number: 00 75 43 20
ANAMNESIS
History of Patient Ilness
History of patient disease
Physical Examination(22/07/2014)
Anamnesis Px Fisik Px Penunjang Resume DiagnosisPx Fisik
Neck: JVP elevated
Cor:I: Ictus Cordis was not visibleP: Ictus cordis was not palpableP: impression of cor’s border was not dilatedA: heart sound I-II normal intensity, regular, murmur (-)Abdomen: liver and
spleen were not palpable, bowel sound (+) normal, ballotement (-)
oedem (-/-)Cold extremities (-/-)
Hemiparese dx
Eye: pale conjunctiva (-/-), icteric sclera (-/-)
Pulmo: vesicular breath sound (+/+), rales (+/+), crackles (+/+), wheezing (-/-)
oedem (+/+)Cold extremities (-/-)
Hemiparese dx
Emergency Room 22/07/2014 (11.47 am)
ER
ECGICVCU(23/07/2014; 05.00 a.m)
ICVCU (23/07/2014)
Laboratory Findings(22/07/2014)
• HB : 16,6 GDS : 274
• HCT : 47 SGOT : 62
• AL : 11,5 SGPT : 150
• AT : 305 Creatinine : 2,4
• AE : 5,51 Ureum : 104
• MCV : 85,6 Na : 138
• MCH : 30,1 K : 5,2
• MCHC : 35,2 Cl : 109
• RDW : 12,5 HbsAg : nonreactive
• MPV : 8,7 Albumin : 3,8
• PDW : 16
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
Radiology(23/07/2014)
CTR >50%cardiomegaly with pulmonal oedema
Echocardiography(03/05/2012)
Excentric LVH with restrictive diastolic disturbanceAbnormality of segmental wall motion (EF : 25%)MR and TR mild
Diagnose
Therapy (22/07/2014)
PLAN• Echocardiography
• Complete the laboratory tests for DM
• Consultation with neurologist
• Cranial CT scan
• Consultation with internist
Physical Examination(23/07/2014)
Anamnesis Px Fisik Px Penunjang Resume DiagnosisPx Fisik
Neck: JVP elevated
Cor:I: Ictus Cordis was not visibleP: Ictus cordis was not palpableP: impression of cor’s border was not dilatedA: heart sound I-II normal intensity, regular, murmur (-)Abdomen: liver and
spleen were not palpable, bowel sound (+) normal, ballotement (-)
oedem (-/-)Cold extremities (-/-)
Hemiparese dx
Eye: pale conjunctiva (-/-), icteric sclera (-/-)
Pulmo: vesicular breath sound (+/+), rales (+/+), crackles (+/+), wheezing (-/-)
oedem (+/+)Cold extremities (-/-)
Hemiparese 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
Neurologic Findings ( 23/07/2014 )
Neurologic Findings ( 23/07/2014 )
Therapy (17/07/2014)
PLAN• Echocardiography
• Complete the laboratory tests
• Cranial CT scan
Case analysis
Case analysis
Case analysis : complication of MI
Case analysis
Case analysis
Case analysis
