CASE REPORT A MAN WITH CHIEF COMPLAINT SHORTNESS OF BREATH SINCE ONE WEEK BEFORE ADMISSION

by: Pralia Winda Sari (04104705254) Citra Pusvitalia (04104705261)

Advisor: Dr. Syamsu Indra, SpPD, K-KV Department of Internal Medicine Mohammad Hoesin Hospital-Faculty of Medicine Sriwijaya University, Palembang 2012

CASE REPORT

Identification

Name : Mr.S Age : 63 years old Sex : Male Address : Sukodadi Status : Married Occupation : Farmer Religion : Moslem Date of admission: January 6th 2012

ANAMNESIS

Chief complaint
Progressive shortness of breath since a week before admission

HISTORY OF ILLNESS
One year before admitted, the patient complained shortness of breath. He felt shortness of breath while activity. Shortness of breath would relieve after taking a rest. He also complained cough with white sputum, fatigue (+), fever (-), swelling of feet (-), defecation and urinate was normal. He went to doctor, and doctor said that he had heart disease.

4 months before admitted, the patient complained shortness of breath was getting worse. He felt shortness of breath after walking to the toilet and relieved after taking a rest. He often woke up in the night because of shortness of breath and cough. He always sleep with 2-3 pillows, fever (-), chest pain (-). He also complained cough with white sputum and swelling of feet. Then he went to doctor, and doctor gave him some medicine but the symptoms were not relieved.

1 week before admitted, the patient complained shortness of breath was more complicated although he took a rest. He always sleep with 2-3 pillows. He also complained cough (+) with white sputum, palpitated (+), chest pain (-), fatigue (+),and swelling of feet (+). Patient went to doctor and reffered to RSMH.
13 days hospitalized, the patient complained shortness of breath decreased, swelling of feet minimal, but he still get cough.

History of Past illness

Diabetic Melitus is denied Hypertension is denied Sore throat is denied Joint pain is denied

History of Family Illness

No body in family has same illness

PHYSICAL EXAMINATION
General Examination Anamnesis and alloanamnesis on January 19th 2012 General appereance: He looked moderately sick Sense : Compos mentis Blood pressure : 130/90 mmHg Pulse rate : 84x/minute Respiration rate : 28 x/minute Temperature : 36,50C Body Weight : 40 kg Body Height : 156 cm BMI : 16,4 kg/m2(underweight)

SPECIFIC EXAMINATION

Skin Skin color is black brown, normal pigmentation, eflorescense, icteric, sianotic or pale on palm and plantar (-), scar (-), hyperhidrosis (-), normal hair growth, good turgor, wet or dry in palpation (-). Lymph nodes There are no enlargement of the lymph nodes on submandibular, neck, axillaries, and inguinal. Head Normocephaly, hair loss(-), symmetrical, alopecia (-), deformity (-), mallar rash (-) Eyes Exopthalmus or endopthalmus (-), pale conjungtivae palpebrae (-), icteric sclera (-), good light response on both of eyes, symmetrical eyes movement, blurry vision (-).

Nose Epistaxis (-), deviated septum (-), normal mucus layer.

Ear Normal both meatus accusticus externus, decreasing hearing ability (-), tenderness mastoideus (-). Mouth Enlargement of tonsil (-), hiperemic pharing (-). Neck JVP (5+0) cmH2O, enlargement of thyroid glands (-).

Thorax Symmetric, retraction (-),Normal shape, venectasis (-), spider nevi ().

Pulmo Anterior I : static and dynamic: right and left lung symmetric P : stem fremitus left is higher than right, crepitation(-), tenderness (-), P : sonor in left lung, dull in right lung A : vesicular (+) decrease in right lung, rales in right lung field (+), wheezing (-) Posterior I : static and dynamic: right and left lung symmetric P : stem fremitus left is higher than right, tenderness (-), crepitation (-) P : sonor in left lung, dull in right lung A : vesicular (+) decrease in right lung, rales in right lung field (+), wheezing (-)

Cor I : ictus cordis can be seen P : ictus cordis can be palpated, thrill (+) P : top border of cor is left ICS II Right border of cor is parasternal dextra line ICS 4 Left border of cor is axilla anterior sinistra line ICS 5 A : HR 100 x/ minute, regular, murmur (+) sistole at all valve, grade 4/6, gallop (-)

Abdomen I : dome-shaped, venectasi (-), scar (-) P : tenderness (-), undulasi (-), hepar palpated two finger from arcus costa and spleen not palpated P : shifting dullness (+) A : normal bowel sound
External genitalia No examination. Upper extremity Pain on joint (-), pale on finger (-), erythema of palm (-), pitting edema (-), clubbing finger (-), tremor (-), chorea (-), subcutaneus nodul (-), marginatum eriteme (-), normal physiological reflex, cyanosis (-) Lower extremity pitting edema (+),

ADDITIONAL EXAMINATION LABORATORY FINDINGS

Hematology ( January 6th 2012) Hemoglobin : 15,3gr% Eritrocyte : 5.000.000 /mm3 Hematocryte : 45 Leucocyte : 7600 ESR : 8 mm/hour Trombocyte : 181.000

Blood Chemistry (January 10th 2012)

Cholesterol Total: 159 mg/dl HDL : 40 mg/dl LDL : 98 mg/dl Triglyceride : 109 mg/dl Uric acid : 2,3 Ureum : 85 mg/dl (15-39) Creatinin : 1,3 mg/dl (0,6-1,0)

Protein total Albumin Globulin Na K

: 5,1 g/dl (6,0-7,8) : 2,2 g/dl (3,5-5,0) : 2,9 g/dl : 128 mmol/I :3,5 mmol/I

Desember 28th 2011 BSS : 96 mg/dl SGOT : 18 U/I (<40) SGPT : 20 U/I (<41)

URINALYSIS

Sediment:

Epitel cell : positive Leukocyte : 2-4/LPB Erytrocyte : 0-1/LPB Cylinder : positive Crystal : positive

Protein : positive Glucose : negative Keton : negative Blood : negative Bilirubin : negative Urobilinogen : negative Nitrit : negative

CHEST X-RAY EXAMINATION (JANUARY 6 TH 2011)

Interpretation:
Bones and soft tissue are well Inspiration is enough Trachea and mediastinum component in the midline Cor: CTR > 50%, enlargement of heart shape, bottle

shape. Pulmo: there is no infiltrate or nodul lesion in both lung field, Right Costophrenicus angle is dome-shaped. Conclusion: Cardiomegaly and Pleural Effusion dextra.

ECG (Januari 8th 2012)

Conclusion: Sinus tachycardia + RAD with low voltage

ECHO (JANUARY 5TH 2012)

Conclusion: mitral valve prolapse

Planning examination
ASTO test

Working Diagnosis
Congestive Heart Failure et causa Mitral Valve Prolapse + Hiponatremia + Hipoalbuminemia

Differential Diagnosis

Congestive Heart Failure et causa Mitral Valve Prolapse Congestive Heart Failure et causa Infective Endocarditis

Treatment
Non

Pharmacology

Bed rest Heart Dietary III O2 support 3 L/minute Fluid restriction

Pharmacology IVFD RL gtt X/minute Furosemide 1 x 20 mg iv Spironolactone 1x 20 mg Digoksin 1 x 0,125 mg Ambroxol 3 x 5 ml Laxadine 3x1C Surgery

Prognostic
Quo ad vitam Quo ad functionam : Dubia ad malam : Dubia ad malam

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