Professional Documents
Culture Documents
Present By
Nur Kurnia Putri Halim
Supervisor
dr. Akhtar Fajar M , SpJP, FIHA
PATIENT’S IDENTITY
• Name : Mrs. KM
• DOB : March 29th 1994(21 yo)
• Adress : Pangkep
• Medical Record :479121
• Admission Date : November 12th 2015
HISTORY TAKING
• General Status
• Moderate illness/ Normoweight/ Compos Mentis
• Vital Status
• Blood pressure : 100/70 mmHg
• Heart rate : 88 x/m
• Respiratory rate : 20 x/m
• Temperature : 36,5 oC
HEAD AND NECK
• No anemic, no icteric
• No cyanosis
• JVP R+1cmH20
LUNG
• Inspection : Symmetry left=right
• Palpation : Mass (-), no tenderness
• Percussion : Sonor
• Auscultation : Vesicular
Rhonchi -/-, wheezing-/-
HEART
• Inspection : Ictus cordis invisible
• Palpation : Ictus cordis isn’t palpable
• Percussion : normal heart size
• Upper border 2nd ICS sinistra
• Right border 4th ICS linea parasternalis dextra
• Left border 5th ICS linea axillaris anterior sinistra
• Auscultation : Heart sound I/II regular, murmur (+) sistolik gr 4/6
LLSB
ABDOMEN
• Inspection : flat, follows breath movement
• Auscultation : peristaltic (+), normal
• Palpation : liver and spleen not palpable
• Percussion : tympani, ascites (-)
EXTREMITIES
• No edema
ELECTROCARDIOGRAM
• Heart rate : 87x/min, reguler
• P wave : 0.08’
• PR interval : 0.12’
• Axis :normoaxis
• QRS complex
• Duration : 0.08’
• ST segment : Normal
• T wave : Normal
• conclusion :
• Sinus rhythm , HR 87 bpm, normoaxis
RADIOLOGY (CXR)
• Cardiomegaly (cti 0.54
) with left to right shunt
ECHOCARDIOGRAPHY
Moderate VSD :
Large VSD :
Increase RV vol
LV pressure > RV Left to right
VSD (hipertrophy,dila
pressure shunt
tation)
Increase
RV pressure > LV Pulmonary Increase vessel
pulmonary
pressure hipertension resistance
blood flow
cyanosis
Right to left
shunt LV volume
(esenmenger overload
syndrome)
Small defects
• asymptomatic
Magnetic
resonance
Echocardiography imaging
Additional (MRI)
Examinati
on
Cardiac Electrocardiography
catheterization (ECG)
Observation & follow up
• Small VSDs
Medical management
• Medium sized vsd
• CHF- treat with diuretics, ACEI
• 2-3 months follow up
• RV & PAH pressures assessed
Surgical
• Large vsd
• Furosemide 1–3 mg/kg per day
• Digoxin 10-20mcg/kg per day
• Captopril 0.5–2 mg/kg per day
• Large VSD with pulmonary hypertension
• VSD with aortic regurgitation
• VSD with associated defects
• Failure of congestive cardiac failure to respond to
medications
THANK YOU