TOPIC 3

Feeling weak and palpitation

CASE

Mrs. Syahrini, a 73-year-old lady, is taken by her family to the emergency room (ER) because of
decreased of consciousness (DOC) about 30 minutes before hospital admission. She has suffered
from feeling weak for 1 week before hospital admission, however, in the last 3 days she also suffered
from palpitation. She could not lie down in the supine position due to shortness of breath (SOB). She
has history of SOB while doing the mild activity for the last 1 year. Because of that, she restricts her
physical activity. About 3 months ago, she suffered from transient loss of consciousness while doing
housework. She got valsartan 80 mg daily, furosemide 40 mg daily, and digoxin 0.25 mg daily from
GP but she does not routinely take medication.

The patient looks normal weight and somnolence. Vital signs reveal blood pressure of 80/57 mmHg,
pulse rate of 130 tpm with a regular pattern, respiratory rate 36 tpm, and oxygen saturation of 87%
with the 10 lpm oxygen supplementation. Physical examination reveals jugular vein distension, apex
pulsation was palpated in the fifth intercostal and left anterior axillary line, heart rate of 130 bpm
with a regular pattern, S3 gallop at the apex, holosystolic murmur grade 4/6 at apex with blowing
quality radiated to the left axilla, ejection systolic murmur grade 3/6 at the upper right sternal
border with blowing quality radiated to the neck, rales in basal area of both lungs, and cold
extremities.

ECG:

1
Chest X-ray:

REFERENCES

1. Lilly LS. Pathophysiology of Heart Disease: A Collaborative Project of Medical Students and
Faculty 6th Edition, 2015.
2. Ponikowski P, Voors AA, Anker S, et al. 2016 ESC Guidelines for the diagnosis and treatment
of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute
and chronic heart failure of the European Society of Cardiology (ESC). Developed with the
special contribution of the Heart Failure Association (HFA) of the ESC. European journal of
heart failure, 2016; 18 (8), 891-975.
3. Thaler M. The Only EKG Book You'll Ever Need 9th Edition, 2017.
4. Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS guidelines for the management of
valvular heart disease. European heart journal, 2017; 38 (36), 2739-2791.
5. Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF. Braunwald's Heart Disease: A
Textbook of Cardiovascular Medicine 11th Edition, 2018.