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Case Report valvular heart diseasePresented By :Ruth FJRSupervised :dr. Pendrik Tendean, Sp.PD
Patient identityName : Mr. SAge : 37 years oldGender : MaleAddress : Mario, BoneMR : 718600Date of admittance : July 9th 2015
History TakingChief complaint: shortness of breathHistory taking: It has been since 1 year before admitted and worsen within the last week before admitted to the hospital and relieved by sitting upright. Paroxysmal Nocturnal Dyspnea(+). Dyspnea On Exercise (+). Chest pain (+) occurs with the shortness of breath, squeezed-like pain and spreads to the back, 20 minutes of duration, palpitation (-) nausea (-) vomitus (-). Cough (-). Fever (-) and fever history was not exist. Hypertension and DM were denied. Defecation & micturition were normal.
PAST ILLNESS HISTORYHistory of cardiac disease before (-) Family history of cardiac disease (-)Cigarrette smoking (+)
Physical ExaminationPresent status: Severe illness / Poor-nourished / ConsciousVital signs:BP: 110/50 mmHgHR: 88 x/ minuteRR: 25 tpm (vesicular)T: 36.8C (axilla)
Physical ExaminationHead : Anemic (-) Icterus (-)Neck : No mass, no tenderness, JVP R+3 cmH2OChest : Rhonchi +/+ (base of lungs) Wh -/-Heart: S1/S2 irregular, systolic murmur grade 4/6 (apex), diastolic murmur grade 3/6
Abdominal : Ascites (-), peristaltic normalExtremities : oedem (-)ECG (7/7/15 )
Rhythm : Sinus rhythm, reguler QRS Rate: Heart rate 100 bpm Axis : Left Axis Deviation P Wave : NormalPR Interval : 0.14 sQRS Complex : 0.08 s, poor R Wave progression, S V1+ R V6ST Segment: ST depression I aVL V5 V6 ST Elevation V3 V4T Wave : T inverted in lead I, aVL, V4, V5, V6Conclusion: Sinus Rhythm, Left Ventricular Hypertrophy Ischemic antero lateral wall
Chest X-RayConclusion :Cardiomegaly with oedem pulmonalRight diaphragm elevatedCVC in the right hemithorax with the tip at the level of Costovertebral Thoracic 8Pleural Efusion bilateralAorta Dilatation
Lab. FindingsResult Reference of valueRBC5.56.106/mm3(3,8 5,8).106/mm3HGB16.6 g/dL12 - 16 g/dLWBC14.103/mm3(4 - 10).103/mm3PLT142.103/mm3(150 - 400).103/mm3PT16.910-14INR1.62APTT28.922-30GDS95 mg/dl< 200 mg/dLUrea89mg/dL10 - 50 mg/dLCreatinine 1.32 mg/dL< 1,1 mg/dLUric acid9.7 mg/ml2,4-5,7Natrium136 mmol/L136-145 mmolKalium4.2 mmol/L3.5-5.1 mmolClorida101 mmol/L97-111mmolresultReference of valueunitsTotal bilirubin4.94
