Cardiovascular

Death Case
Presented by
dr. Syahriani

PATIENT IDENTITY
MR number : 36 72 64
Name
: Mr. Yambo
Gender : Male
Age
: 40 y.o
Date administered : 15/07/2010

HISTORY TAKING
Chief Complaint : Oedema of both foot
History taking:

Oedema of both foot is felt since 1 month before

hospitalization. This complaint becomes severe
every day.

Shortness of breath (+) is felt since 2 days before

hospitalization. History of shortness of breath
before (+). Chest pain (+) It is primary happened
on the centre of chest, no penetrate to the back,
and no spreading to the left arm

Cough (+) is felt since 2 days before

hospitalization. Cough with blood and the colour is
fresh red .

 Fever (-), history of fever (-)

Nausea (+), vomiting (+), epigastric

pain (+)
Defecation : normal
Micturition : normal

History of Disease :
History of cardiac disease (+) . This
patient is diagnosed valve disease since
38 years old but this patient did not
control regularly.
History of hypertension (-).
History of DM (-).

PHYSICAL
EXAMINATION
Generalis Status : Severe illness/ Conscious
Vital Sign

: Blood Pressure : 90/50 mmHg

Respiratory Rate : 28 x/minute
Heart Rate
: 72 x/minute
Temperature : 36,1oC

PHYSICAL EXAMINATION
Regional status
Head : anemia (-), icterus(+), cyanosis(-)
Neck : JVP R+4 cmH2O
Thorax : Breath Sound : bronchovesicular,
Additional Sounds : Rh: - -, Wh: -/++
Cor

: SI/SII regular
Additional Sounds : diastolyc murmur (+) grd. 5/6

Abdomen: Ascites (+) Shifting dullness (+)

Hepar is palpable 3 digity under arcus costa
Extremity

: oedema +/+

Genitalia : Oedema penis (+)

LABORATORY
EXAMINATION
Routine Blood (15-07-2010)
WBC : 11.000 / uL
RBC
: 4,87x106 /uL
HGB
: 12,5 g/dL
PLT
: 170x103 / uL
Electrolyte (15-07-2010)
Sodium
: 124 mg/dL
Pottassium : 5,5 mg/dL
Chloride
: 93 mg/dL

LABORATORY
EXAMINATION
Chemical Blood Test (15-07-2010)
GDS : 95 mg/dl
Ureum
: 48 mg/dL
Creatinin : 1,1 mg/dl
Urat Acid: 5,7 mg/dl
Total Chol. : 114 mg/dl
SGOT: 37 u/I
Trigliserida : 121 mg/dl
SGPT : 15 u/I
HDL : 7 mg/dl
CK
: 104 u/l
LDL
: 92 mg/dl
CKMB
: 20 u/l
Trop T
: 0,44 ng/ml

ADVANCED
EXAMINATION

ECG
-Sinus rhythm, HR 98x/min
- RAD,RVH, P mitral
-OMI high lateral
-Inferior ischemia
-Whole wall anterior ischemia

CXR
(15-07-2010)
Cardiomegaly with congestive sign
Susp. Mitral Heart Disease

WORKING DIAGNOSIS
CHF NYHA IV ec susp. MS
Cardiogenic Shock
Electrolyte Imbalance

INITIAL MANAGEMENT
Half sitting position
O2 3-5 litre per minutes
NaCl 0,9% 200cc in half an hour
IVFD NaCl 0,9% : 10 drips/minutes
Dobutamine 5 g/body weight/minute
Lasix 2 amp/inj./iv
Fasorbid 5 mg/sublingual (if necessary)
Aspilet 80 mg 0-1-0
Simarc 2 gr 0-0-1
Laxadyn Syrup 0-0-2 C

Alprazolam 0,5 mg 0-0-1

NaCl 3 % within 2 days, 1 calf per day
Catheterization
Laboratorium :
CK-CKMB, Troponin T, Lipid Profile, Uric
Acid, Total Bilirubin, Indirect Bilirubin,
Total protein, Albumin.

FOLLOW UP

Date
16/07/10
BP 90/60
P 98 x/i
RR 24 x/i
T 36,6 C
Fluid
Balance :
IP 900
OP 2420
- 1520

Follow Up
Subjectives :
Shortness of breath (+),
chest pain (-), cough (+)
blood (+).
Defecation: (-) since 4 days ago
Micturition: per catheter

Therapy

Half sitting position

O2 3-5 litre per
minute
IVFD NaCl 0,9% : 20
drips/minutes
NaCl 0,9% 200cc in
half an hour
Objectives :
Dobutamine 5 g/body
-Anaemic (-)/icteric
weight/minute
(+)/,cyanotic (-).
Lasix amp
--DVS : R +4 cmH20
Furosemide 40 mg
1-0-0
-Thorax:
Fasorbid 5
BS (Breathing Sound)
mg/sublingual (if
vesicular, Rh - Wh
necessary) stop
-/Aspillet 80 mg 0-1-0
- Simerc 2 gr 0-0-1
+ +
Laxadyn Syrup 0-0-2
-Cor S1 S2 regular, diastol Ceftriaxone 1
gr/12hr/iv
murmur (+)
Digoxin 0,25 mg 0-1-0
Ramipril 5 mg 0-1-0

Date

Follow Up
-Abdomen :
Peristaltic (+), Defans
muscular (-), shiffting
dullness (-)
-Extremity : oedema -/Lab
(16-7-10):
Albumin 3,3
A : CHF NYHA IV e.c suspect
MS

Therapy
Alprazolam 0.5 mg
0-0-1
Codein tab 1-1-1
Planning :
a. Monitoring Lab.
result
b. Echocardiography

Follow Up
Echocardiography result :
-Global Normokinetic
-LA, LV, RV dilatation with
LV D shaped
-TAPSE 1.1 cm
-MS mid-severe , mVA 0.7
cm
-MR trivial-mild
-PR mild
-TR severe, TVG 60
mmHg
-PH severe, mPAP 45
mmHg
-Suspect trombus in LA
-Chronic pericard efussion

Therapy

Date
17/07/10
BP 110/70
P 100 x/i
RR 19 x/i
T 36,7 C
Input:
1060
Output :
2200
=-1140cc

Follow Up

Therapy

Subjectives :
Shortness of breath (-), chest
pain (-), cough (+) blood (-).
Objectives :
-Anaemic (+)/icteric (-)/
cyanotic (-).
-DVS R-1cmH2O
-Thorax:
BS (Breathing Sound)
bronchovesiculer
Rh Wh -/- + +
Heart sound S1-S2 not pure,
diastolic murmur +, gr.5/6
-Abdomen: Peristaltic (+),
normal
-Extremity : oedema +/+
Assessment
- CHF NYHA IV e.c MS + TR
-severe pulmonary

IVFD NaCl 0,9% : 20

drips/minutes
Aspilet 80 mg 0-1-0
Simarc 2 mg 0-0-1
Laxadyn Syrup 0-0-2
Alprazolam 0,5 mg 0-0-1
Dobutamine 5 g/kgBW/min
7 g/kgBW/min/sp
Ceftriaxone 1 gr/12hr/iv
Digoxin 0,25 mg 0-1-0
Codein 3x10mg
Ramipril 0,5 mg 0-1-0
Furosemide 40 mg
1-0-0

Date
18/07/10
BP 80/60
P 95 x/i
RR 22x/i
T 36,8 C
Input:
2620
Output :
3220
=-1965cc

Follow Up
Subjectives :
Shortness of breath (+),
cough (+) blood (-).
Objectives :
-Anaemic (+)/icteric (-)/
cyanotic (-).
-DVS R-1cmH2O
-Thorax:
BS (Breathing Sound)
bronchovesiculer
Rh - Wh -/+ +
+ +
Heart sound S1-S2 regular,
diastolic murmur (+)
-Abdomen: distended,
Peristaltic (+), normal
-Extremity : oedema +/+
Assessment
- CHF NYHA IV e.c MS + TR
- severe pulmonary
hypertension

Therapy
O2 NRBN 8-10 litre/min
IVFD NaCl 0,9% : 20
drips/minutes
Aspilet 80 mg 0-1-0
Simarc 2 mg 0-0-1
Dobutamine 7
g/kgBW/hmin/sp
Ceftriaxone 1 gr/12hr/iv (3)
Digoxin 0,25 mg 0-1-0
Furosemid 40mg 1-0-0
Codein 3x10mg
Ramipril 2,5 mg 1-0-0

Date
18/07/10
11.00

Follow Up
BP: 60/palpation, SaO2 86%
HR: 106x/i
RR : 32 x/i
-Thorax:
BS (Breathing Sound)
bronchovesiculer
Rh + +
Wh -/+ +
+ +

-Lab: GDS 53mg/dL

Therapy
O2 8-10 ltr/min (face mask)
Dobutamine
7g/kgBW/min/sp
Dextrose 40% 2 flacon
Planning:
Cito Blood gas analysis,
electrolyte, GDS, ureum,
creatinine

Date
18/07/10
11.30

Follow Up

Therapy

BP: 80/65 SaO2 92%

HR: 117x/i
RR : 32 x/i
-Thorax: BS bronchovesiculer
Rh + +
Wh -/+ +
+ +

12.00

BP: 80/65
RR : 34x/i
Lab: GDS 73

Dextrose 40% 1 flacon

13.00

BP: 80/palpation HR : 100x/i

Lab: Blood gas analysis
pH 7,235
PCO2 29,8
BE -12,7
HCO3 12,9
Metabolic asidosi with partial
Compensated

Bicnat 100 mg in NaCl0,9%

200 cc for 4 hours

Date

Follow Up

18/07/10
13.15

BP: 80/palpation
Lab : GDS 86

14.00

BP: 80/palpation
Lab : GDS 82

15.00

BP: 80/palpation
Lab : GDS 86

16.00

Pupil:maximal midriatic
BP : tdk terukur
P: tdk teraba
death

Therapy
Dextrose 40% 1 flacon
Ambu bag with Jackson
Rees

Dextrose 40% 1 flacon

Dobutamine
10mcg/kgBW/min

thanks