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CHF ec CAD

AND
LYMPHADENITIS
TB
Prajnya Paramitha N
030.08.192

Identity
Name
Age
Gender
Adress
Occupation
Religion
Marital status
Race
Education

: Mr. S
: 71 yo
: Men
: Bojong, Karawang
: Unemployed
: Islam
: Married
: Sundanese
: Senior high school

Admission to hospital on 16th of October 2012

ANAMNESE
Autoanamnese on 18th of October 2012 at 10.30

History of present disease


A 71-year-old male presented to RSUD Karawang with a one-

week history of shortness of breath. The symptom occurs


especially during activities such as walking and having daily
meals. Patient also complaint of waking up from sleeping due
to breathlessness that occurs a few hours after lying down but
relieves after he sits, therefore he needs 5 pillows during his
sleep. Patient felt palpitation occasionally and denied of
having hacking cough with pinkish froth.
Patient complained of swellings on all of his extremities since
one week before being admitted to the hospital in which
making him unable to walk and have difficulties to move his
extremities freely. His scrotum has also been swollen for 2
days. Due to this swellings, patient complained of a rapid
weight gain around 5kgs in 10 days or less.

History of present disease


He also felt fatigue since 10 days ago.
He

declared of having productive cough for


approximately 20 days with mucous phlegm in a range of
colors from white to green which is hard to be coughed
out.
Defecation was normal. Urination was normal
There were no complaints of chest pain, fever, decrease
of appetite, difficulty nor pain in swallowing, tension
headache, bloating stomach, nor decrease of
consciousness.

History of past disease

Family history
No one in his family has a symptom or disease like him
Hypertension (-), Dyspepsia (-), Liver disease (-), Kidney

disease (-), Cancer (-), Diabetes Mellitus (-)

Habitual history
Drinks coffee 4 cups a day
Smokes 5 cigarettes a day
Eats rice, vegetables, and tempe
Drinks plenty of water up to 8 glasses a day
Drugs (-), Tatoo (-), Alcohol (-)

PHYSICAL
EXAMINATION

General condition

THORAX

T
R
A
HE

THORAX
Inspection

G
N
U
L

: Symmetrical
Palpation
: Equal vocal resonance
Percussion
: Sonor in both lungs
Auscultation : Vesicular breath sound in both
lung,ronchi (+/+),wheezing (-/-)

ABDOMEN
INSPECTION

Brown skin, symmetrical, supple,


flat
Icteric (-), Caput medusae (-),
spider nevi (-)

AUSCULTATION

Bowel sound (+) , venous hum (-),


arterial bruit (-)

PERCUSSION

Tympani
Shifting dullnes (-)

PALPATION

Turgor N
Tenderness (-)
Hepatomegali (+), splenomegali (-)
Hepatojugular reflex (+)

EXTREMITY
Warm acral

Edema

Wet

Deformity (-), brown skin , spider nevi (-), palmar erythema (-),
pale (-), icteric (-), flapping tremor (-), swelling on all
extremities, CRT < 2secs

LABORATORY
Result

Normal

Hemoglobin

11,5

12-17 gr/dL

Leukocytes

32.400

5.000 10.000

Trombocytes

443.000

150.000 450.000

Hematocrite

34

37-43%

Ureum

42

10-45 mg/dl

1,23

0.4-1.5 mg/dl

SGOT

28

<40/ul

SGPT

18

<40/ul

Haematology

Creatinin

CXR

ECG

RESUME

DIFFERENTIAL DIAGNOSIS
CHF ec CAD
CHF ec
Cardiomyopat
hy
CHF ec RHD
CHF ec HHD
COPD

Treatments
Pharmacology
KAEN 3B + Furosemid 2 amp
Tab Aldacton e1x12,5mg
Tab Thrombo Aspilet 1x80mg
Tab Clopidogrel 1x75mg
Tab Captopril 3x25gram
Tab Alprazolam 1x0,5mg
Tab Ambroxol 3x1
Tab sublingual ISDN 3x2,5mg
Caps Hepamax 3x1
Tab ATP Dancos 2x1
Tab Rifampycin 450mg 1x1
Tab Pyrazinamid 500mg 3x2
Tab Pulna 1x3
Non pharmacology
HCHP diet, low sodium diet
Education

Suggested examination
Echocardiography
BNP
Acid-fast bacillus
smear
Sputum
Fine-needle
aspiration biopsy
Surgical excision
biopsy

Blood gas analysis


Electrolyte

Prognosis
Ad Vitam
Ad Fungtionam
Ad Sanationam

: Dubia ad Malam
: Dubia ad Malam
: Dubia ad Malam