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Muh.

Rahmat Ridha
C111 11 318

Supervisor: Dr. dr. Muzakkir Amir, Sp.JP.


FIHA

Patients Identity

Name
Age
MR
Admitted
2015

: Mr. A
: 37 y.o.
: 731908
: November 4th ,

History Taking

Chief complaint: Shortness of breath


Present illness history:
Shortness of breath experienced since about 3 weeks
ago. Shortness of breath arise slowly, is ongoing, and
become heavy one week ago. Shortness of breath is
not influenced by the activity and time. Shortness of
breath is slightly reduced when patients sit up and
become heavy when patient move. This complaint
following cough with frothy mucus and accompanied
by chest pain that feels hot and does not spread to the
left arm. Chest pain is somewhat reduced when the
patient sits bent forward. There is 1 week history of
fever before shortness first appeared accompanied by
yellow eyes noticed by family. Defecate and urinate in
normal limit

Risk Factor and Past Illness

No smoking, no alcoholic, no
obesity.
No hipertension, no diabetes
mellitus, no coronary artery
disease.

Physical Examination

General state :
Moderate illness/well nourished/

conscious

Vital status
Blood Pressure
Pulse Rate

: 100/70 mmHg
: 105 tpm (reguler)
Respiratory Rate : 26 tpm
Temperature
: 36,5 0C (axilla)

Physical Examination

Head
Neck
Lung

:
:
:

anemic (-), sclera icteric (+)


JVP R+7 cmH2O (300)

Inspection

: symmetry left = right


Palpation
: mass (-), no tenderness
Percussion : sonor left = right
Auscultation
: vesicular, ronchi +/+,
wheezing -/-, decrease in basal lung

Physical Examination

Cor

Inspection
Palpation
Percussion

: ictus cordis not visible


: ictus cordis not palpable, thrill (-)
:

dull, Upper border 2nd ICS linea parasternalis


sinistra, Right border 4th ICS linea parasternalis
dextra, Left border linea axillaris anterior sinistra
Auscultation : heart sound I/II pure, regular,
murmur (-), soft heart sound

Electrocardiography

Electrocardiography

Sinus: Sinus rhythm


Heart rate: 105x / min regular
Axis: Axis normo
P wave: 0:08 seconds
PR interval: 0:16 seconds
QRS complex: low voltage, duration of 0.08
seconds
ST Segment: Normal
Conclusion: Sinus tachycardia, HR: 105x / min,
Normoaxis, low voltage

Laboratorium (04/11/15)

Fluid Analysa (04/11/15)

Microbiology Analysa
(05/11/15)

Citology Analysa (04/11/15)

Malignant cells (non-small cell carcinoma)

X-ray Thoracs

Cardiomegaly with oedem pulmonal


Pleural Efusion Dextra

Echocardiography

Pericardial Effusion

Diagnosis
Massive pericardium effusion / Impending Heart
tamponade + pleural effusion Dekstra

Treatment
Pericardiosentesis
Hepar diet 1700 kkal/day
Nacl 0,9% 500 cc/24 hour/iv
Oksigen 4 liter/minute
Ceftazidin 1 gram/12 hour/intravena
Ketorolac 30 mg/8 hour/iv prn
Ranitidin 50 mg/8 hour/iv
Maxiliv 1 tab/12 hour/oral
Codein 10 mg/12 hour/oral

DISCUSSION

Definition

The Pericardial effusion is


an abnormal accumulation
of fluid within the
pericardium

Anatomy and Function

Anatomy and Function

Anatomy and Function


The pericardium appears to serve three functions:
(1) it fixes the heart within the mediastinum and
limits its motion,
(2) it prevents extreme dilatation of the heart
during sudden rises of intracardiac volume, and
(3) it may function as a barrier to limit the spread
of infection from the adjacent lungs.

ETIOLOGY

ETIOLOGY

Pathophysiology
Three factors determine whether a pericardial
effusion remains clinically silent or whether
symptoms of cardiac compression ensue:
(1)the volume of fluid,
(2)the rate at which the fluid accumulates, and
(3) the compliance characteristics of the
pericardium.

Pathophysiology

Clinical Feature
1. Chest pain or discomfort such as
suppressed by improving the
characteristics of sit / lean forward bending
position worsened in the supine position
2. Shortness of Breath
3. Hoarseness
4. hiccups
5. Syncope
6. Tachypnea
7. The stomach feels full and hard to
swallow
8. Palpitations

Physical Examination

Cardiac Tamponade (Becks Triad)


(1) jugular venous distention;
(2) systemic hypotension; and
(3) a small, quiet heart on physical examination, a
result of the insulating effects of the effusion.

Diagnostic Studies
Laboratory
1. Electrolytes
2. Complete blood count (CBC)
3. Cardiac enzymes
4. Thyroid stimulating hormone
5. Rheumatoid factor, immunoglobulin complexes,
antinuclear antibody test (ANA)
6. Test specific infectious diseases

Diagnostic Studies
Electrocardiography: Showed sinus tachycardia, low
voltage, concave ST segment elevation, electrical
alternans.

Diagnostic Studies

X-ray thoracs: "Water bottle-shape


CT scan: Fluid density surrounding heart
Echocardiogrphy: echo free space room front under
the sternum and the rear wall of the heart

Treatment