CASE REPORT

80 years old male came to the

emergency departement with
worsened shortness of breath and
chest pain since 2 days ago

Berka Phillia Ningrum

030.15.042
Present Patient presented to the emergency department with
medical shortness of breath since the past 8 days and worsened
history since 2 days ago. shortness of breath become heavy in
sleeping position and feel better in sitting position.
Patient needs at least 3 pillows to sleep and said often 2
wake up at night due to shortness of breath.
Present Shortness of breath accompanied with chest pain. Chest
medical pain feels like someone strangled his neck and
history penetrated to the back.
Swollen on both legs show on sudden onset since 2 days
ago. Patient easily feels tired on light physical activity 3
like going to the bathroom.
Patients have complaints of cough with thick- white
phlegm for 2 weeks. Patient denied any fever.
 Past Diabetes melitus(-), Hypertension (-), heart disease
medical (-), kidney disease (-), pulmonary disease(+)
history Patient had a history treated in cikampek ward RSUD
Karawang 2 months ago with pneumonia and COPD.
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Family’s Diabetes melitus(-), Hypertension (-), heart disease
medical (-), kidney disease (-), pulmonary disease(-)
history

5
Treatment Patient seeks medical treatment at puskesmas for
history shortness of breath and chest pain, and immediately
referred to emergency departement RSUD Karawang.

6
Patient’s The patient had a 59-year-old smoking habit and had
habit stopped 1 year. Most cigarettes consumed 2 packs / day.
Patients like to eat fried and oily foods.

7
 Physical  Consciousness: compos mentis
examination  Impression of pain: moderate
 BMI : 56,7/1,632 = 21,32 kg/m2 (normal)
 Vital sign
Blood pressure : 90/60 mmHg 8
Heart rate : 68 x/minute
Respiration rate : 24 x/minute
temperature : 36,5°C
SpO2 : 90%
 Physical Eyes:
examination Conjungtiva pallor -/-, Sclera icterus -/-
Ears:
Deformity-/-, hyperemia -/-, edema -/-, serument -/-Nose:
Deformity (-), septum deviation(-), mucus (-) 9
Throat:
Tonsil T1/T1, hyperemia (-)
Mouth:
Sianosis (-), dry(-), hyperemia (-)
 Physical Neck:
examination Tyroid gland and lymph nodes within normal limit,
increased JVP
Thorax:
Inspection: lesion (-), chest wall movement symmetric, 10
intercostal retraction (-), pulsation of ictus cordis at ± 4 cm
lateral to ICS VI midclavicular line
Palpation: fremitus vocals are not weakened or increased
in both lungs, ictus cordis palpable at ± 4 cm lateral to ICS
VI midclavicular line
 Physical Thorax:
examination Percussion: pulmonary and hepatic border are within
normal limits. right heart border on ICS V right sternal
line and left heart border at ± 4 cm lateral ICS VI left
midclavicularis line. 11
Auscultation: the first and second heart sounds regular,
gallops (-), murmur (-), vesicular breath + / +, rhonchi + /
+, wheezing - / -
 Physical abdomen:
examination Inspection: convex form, icterus (-), hyperemia (-), nevi
spider (-), mass (-), lesion (-)
Auscultation: 3x/minute bowel sounds, arterial bruit (-)
Palpation: supple, mass (-), tenderness in epigastric region 12
(+), splenomegaly (-), hepatomegaly (+) 1 cm below arcus
costae, kidney ballottement (-), undulation (-)
Percussion: shifting dullness (-), timpani entire quadrant
 Physical Extremity:
examination Lesion (-), deformity (-), CRT <2s,
Warm + + edema - -
+ + + +

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 Hematology (18/6/2019)
Laboratory assessment result unit reference value
test Hemoglobin 13,1 g/dL 13,2 – 17,3
Erythrocytes 4,41 x106/µl 4,5 – 5,9
Leucocyte 6,33 x103/µl 4,4 – 11,3
Thrombocyte 199 x103/µl 150 – 400 14
Hematocrit 38,8 % 40 - 52
MCV 88 fl 80 - 96
MCH 30 pg 28 - 33
MCHC 34 g/dl 33 - 36
RDW-CV 14,5 % 12,2 - 15,3
Laboratory Chemistry (18/6/2019)
test assessment result unit reference value

Random glucose test 114 mg/dL 70-110

Ureum 44,6 mg/dL 15.0-50.0 15

Creatinin 1,16 mg/dL 0.50-0.90
chemistry (19/6/2019)
Natrium 137 mmol/L 134-143
Kalium 3,2 mmol/L 3,7-5,3
Chlorida 103 mmol/L 98.0-107.0
ECG

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ECG ECG interpretation:
1. Sinus rythm tachycardia
2. Heart rate: 150 x/minute
3. Heart axsis : left axis deviation
4. QRS complex: Q patologist wave V1-V4 17

impression: old anteroseptal MCI

 Echo- Measurement
cardiography LA : 43 mm LV IVSd : 9 mm IVSs : 12 mm
Aortic root : 40 mm EDD : 54 mm ESD : 45 mm
LA/Ao : mm PWd : 10 mm PWs : 13 mm
RV : mm EF : 35%
EPSS : 1,8 cm

Comment: 18
• CHF,CAD Katup :
• Dimention of heart chamber • Ao 3 cuspis, calcified (+) at the valve end, AR mild
Ao, RA,LA,LV dilatation (PHT 600 ms)
• LVH (-) • MR moderate
• •
LV contractility decreased, EF 35% TR moderate, PR mild
• Doppler : E/A fusi, Ao Vmax 0,6 m/s, mPAP 36 mmHg
• RV contractility decreased, TAPSE
• Other : PH (+)
1,2 cm
• Segmental analysis: hypokinesia
anterior, anterior septal wall
Diagnosis Working diagnosis: Differential diagnosis:
• CHF causes by old • COPD
anterior MCI • Cor pulmonal
• Pneumonia
• Renal failure 19
Therapy  Lasix 2x40 mg IV
 Spironolacton 1x12,5 mg tab
 Aspilet 1x80 mg tab
 Atrovastatin 1x20 mg tab
 Captopril 3x6,25 mg tab 20
 Day 1 (19/6/2019)
S Patient still feeling shortness of breath (+), cough with thick- white phlegm (+), chest pain decreased (+), the stomach feels tight (+)

Follow up O Consciousness: compos mentis

Impression of pain: mild
day 1 Vital sign :
Blood pressure : 90/70 mmHg
Heart rate : 109 x/minute
Respiration rate : 24 x/minute
temperature : 36,3°C
SpO2 : 98%
head : normocephal, CA -/-, SI -/-
Neck : thyroid gland and lymph nodes within normal limit
Thorax : the first and second heart sounds regular, gallops (-), murmur (-) 21
vesicular breath + / +, rhonchi + / +, wheezing - / -
Abdomen : Supple, bowel sounds (+), tenderness (-)
Ekstremitas : warm edema

+ + - -
+ + + +
A CHF causes by old anterior MCI
P  Lasix 5mg/hour
 Spironolacton 1x12,5 mg tab
 Aspilet 1x80 mg tab
 Atrovastatin 1x20 mg tab
 Captopril 3x6,25 mg tab
 Day 2 (20/6/2019)
S Patient feeling shortness of breath (+), cough with thick- white phlegm (+), chest pain decreased (+), the stomach feels tight (+),
nausesa (+), bloated (+)
Follow up O Consciousness: compos mentis
Impression of pain: mild
day 2 Vital sign :
Blood pressure : 80/70 mmHg
Heart rate : 90 x/minute
Respiration rate : 24 x/minute
temperature : 36,4°C
SpO2 : 96%
head : normocephal, CA -/-, SI -/-
Neck : thyroid gland and lymph nodes within normal limit
Thorax : the first and second heart sounds regular, gallops (-), murmur (-) 22
vesicular breath + / +, rhonchi + / +, wheezing - / -
Abdomen : Supple, bowel sounds (+), tenderness in
Ekstremitas : warm edema
- + -
+ + - - - + -
+ + + + - + -
A CHF causes by old anterior MCI, hypokalemia
P  Lasix 2x40 mg IV
 Spironolacton 1x12,5 mg tab
 Aspilet 1x80 mg tab
 Atrovastatin 1x20 mg tab
 Captopril 3x6,25 mg tab
 Day 3 (21/6/2019)
S Patient still feeling shortness of breath (+), cough with thick-white phlegm (+), chest pain (-), the stomach feels bloated (+), nausea
(-)
Follow up O Consciousness: compos mentis
Impression of pain: mild
day 3 Vital sign :
Blood pressure : 90/60 mmHg
Heart rate : 68 x/minute
Respiration rate : 24 x/minute
temperature : 36,6°C
SpO2 : 98%
head : normocephal, CA -/-, SI -/-
Neck : thyroid gland and lymph nodes within normal limit
Thorax : the first and second heart sounds regular, gallops (-), murmur (-) 23
vesicular breath + / +, rhonchi + / +, wheezing - / -
Abdomen : Supple, bowel sounds (+), tenderness (-)
Ekstremitas : warm edema

+ + - -
+ + + +
A CHF causes by old anterior MCI
P  Lasix 2x1 IV
 Spironolacton 1x12,5 mg tab
 Aspilet 1x80 mg tab
 Atrovastatin 1x20 mg tab
 Captopril 3x6,25 mg tab
 Day 4 (22/6/2019)
S the patient had no complaints

Follow up O Consciousness: compos mentis

Impression of pain: good
day 4 Vital sign :
Blood pressure : 90/60 mmHg
Heart rate : 68 x/minute
Respiration rate : 21 x/minute
temperature : 36,6°C
SpO2 : 98%
head : normocephal, CA -/-, SI -/-
Neck : thyroid gland and lymph nodes within normal limit
Thorax : the first and second heart sounds regular, gallops (-), murmur (-) 24
vesicular breath + / +, rhonchi -/ -, wheezing - / -
Abdomen : Supple, bowel sounds (+), tenderness (-)
Ekstremitas : warm edema

+ + - -
+ + - -
A CHF causes by old anterior MCI
P  Lasix 1x1 tab
 Spironolacton 1x12,5 mg tab
 Aspilet 1x80 mg tab
 Atrovastatin 1x20 mg tab
 Captopril 3x6,25 mg tab
Assessment  Angiography
plan  Profile lipid

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Prognosis • Ad vitam : dubia ad bonam
• Ad fungtionam : dubia ad malam
• Ad sanationam : dubia ad malam

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Thank you.
Any questions?