Scribd Logo
Upload

Welcome to Scribd!

  • 7 views

    CHF

    Uploaded by

    Liya Anjelina

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    CHF

    Uploaded by

    Liya Anjelina
    7 views14 pages

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    7 views14 pages

    CHF

    Uploaded by

    Liya Anjelina

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 14

    Duty Report

    21 MEI 2021
    Asenopita, female, 24 yo, HCU 03
    Chief Complaint :
    • Breathlessness increased since 4 days ago

    Present Illness History :


    • Breathlessness increased since 4 days ago, has been felt since 1
    month ago. Breathlessness affected by activity, not affected by
    weather or food.
    • Chest pain (-)
    • Fever since 4 day ago, fever not really high, no excessive sweating.
    • Cough since 4 day ago, sputum (+) blood (-)
    • Nause (+) and vomit (-)
    • History of swelling both of leg (+)
    • post partum 5 days ago
    • Defecation and micturition was normal
    • Patient was transferred from Yellow zone
    Pass Illness History :
    • History of HT (-)
    • History of DM (-)

    Social and Family History


    • There is no family who had same illness
    Physical Examination
    • General appearance : moderate
    • Consciousness level : CMC
    • BP : 100/70 mmHg
    • HR : 98 x/minute
    • RR : 20 x/minute
    • T : 37
    • Sat : 99%
    • Skin
    Turgor normal
    • Lymph nodes
    No enlargement on the neck, armpit and thigh area
    • Head
    Normocephal
    • Eye
    ◦ Conjunctiva anemic (-)
    ◦ Sclera icteric (-)
    • Neck
    ◦ JVP 5-2 cm H2O
    • Lung :
    ◦ Inspection : normochest, symmetric static and dynamic
    ◦ Palpation : fremitus increased at both of lung
    ◦ Percussion : sonor
    ◦ Auscultation : bronchovesicular, ronchi +/+ in bilateral
    pulmonary field, wheezing -/-

    • Cor :
    • Inspection : ictus not seen
    • Palpation : ictus is palpated at 2 finger medial LMCS ICS VI
    • Percussion :
     Left border : 2 finger medial LMCS ICS VI
     Right border : linea sternalis dextra
     Upper border : RIC II
    • Auscultation : Heart sound regular, murmur (-)
    • Abdomen :
    • Inspection : enlargement (-)
    • Palpation : unpalpaple
    • lien not palpable
    • Percussion : tympani
    • Auscultation : bowel sound (+) normal

    • Extremities :
    • Oedema -/-
    Laboratory
    Hb 13.9 g/dL

    Ht 44 %

    WBC 25.010 /mm3

    Platelets 194.000/mm3

    Diff count 0/0/88/7/5/

    Ur/Cr 30/1.4 mg/dL

    SGOT/ SGPT 30/11 U/L

    Alb/ Glb 2.3/3.1 g/dL

    PT/APTT/INR/DDimer 10.2/28.7/0.92/ >10.000

    Na/K/Cl 135/3.6/107

    ph/ pco2/po2/hco3/be/so2 (4/4) 7,436/ 32.1/ 140.4/ 21.9/-2.6/ 98.9%


    Troponin I 64
    ECG

    • Irama sinus, HR : 99x/m gel P : 0.08, QRS :<0.12, segment ST elevasi


    (-), depresi (-), gel T inverted (+) V3-V4, axis : normal
    • Kesan : sinus rythm HR 99 dengan RBBB
    Chest X-Ray
    Working Diagnose
    • CHF FC II ec PPCM
    • Hospital acquired pneumonia
    Therapy
    • Rest/ cor diet 1500 call
    • O2 3 lpm
    • IVFD NaCl 0,9% 12 hours/kolf
    • Furosemid 2 x 20 mg
    • Inj Cefepime 3x2 gr iv
    • Inf Levofloxacine 1x 750 mg iv
    • N-acetylsistein 3x200 mg po
    • Paracetamol 3x500 po (K/P)
    • Atorvastatin 1 x 20 mg
    • Bisoprolol 1 x 2,5 mg
    Plan
    • Echocardiografi
    • Culture sputume

    You might also like