Post on 03-Jun-2018
8/12/2019 case report peripartum cardiomyopathy
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Lecturer :
Prof. DR. dr. Moch. Fathoni, Sp. JP(K), FIHA
By:Fitrian Sufianasari (G99122048)
8/12/2019 case report peripartum cardiomyopathy
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Name : Mrs. S.MAge : 30 years oldGender : FemaleReligion : MoslemOccupation : Housewife
Address : Jebres, SurakartaMedical Record : 01224878Hospitalized : January 15 th 2014
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SHORTNESS OF BREATH
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• Patient has been complaining shortness ofbreath , getting worse in two days beforeadmission to the hospital. It is triggered byactivity and not relieved by rest .
• Patient slept with three pillows and morecomfortable on seat position, often awakenedat night due to dyspnea.
•
Ankle swelling (+) 2 days before admission.• Productive cough with white sputum (+) since 2days before admission
• Palpitation (+), chest pain (-)
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• This complaint occurred 3 month after she hasdelivered her 2 rd baby with sectio caesarean 6month ago .
• After the delivery, patient felt fatigue and bothof her leg were swelling . Patient also could notdo any activity after delivery because ofdyspnea.
Patient was hospitalized in RSDM 3 months ago.Diagnosed with PPCM and given medicine:furosemid, captopril, ISDN and spironolacton.But patient didn’t control.
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• History of hypertension : (-)During the pregnancy : (-)• History of diabetes mellitus : (-)• History of asthma : (-)• History of allergy : (-)•
History of heart disease : (-)
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• History of hypertension : (-)• History of diabetes mellitus : (-)• History of asthma : (-)• History of allergy : (-)• History of heart disease : (-)
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• 2-3 meals a day, with rice, vegetables,
soya beans (tofu and tempe), she eatsegg and meat occasionally.
NUTRITIONALBEHAVIOR
• Doesn’t smoke. Doesn’t drink alcohol.LIFE STYLE
• She is an unemployment with 1 husbandand 2 children. Her husband works as alabour. Paid using BPJS facility.
SOSIOECONOMIC
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• General Condition : breathlessness, Compos mentis
•
Vital Signs :BP =100/70 mmHgHR = 120 bpm, reguler, normal intensityRR =28 times/minute
Temperature = 36,2 ° C (axillar)
Nutritional status : Height 155 cm, weight 60 kgNutritional status = normoweight
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Eyes : Pale conjunctiva ( +/+),Icteric conjunctiva (-/-)
Neck : JVP was increased R+ 5 cm ,No enlargement of lymphonode
Thorax : normochest, symmetrical,intercostal retractions (-)
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Heart :
- Inspection :Ictus cordis was seen at SIC VI Linea Axilaris Anterior Sinistra, left andright ventricle activity was increased
- Palpation :
Ictus cordis was palpable at SIC VI 3 cm lateral of Linea Axilaris AnteriorSinistra, heaving (+), thrill (-)
- Percussion :1. Upper limit of the right heart: ICS II, linea parasternalis dextra2. Bottom right cardiac border: ICS IV, linea parasternalis dextra3. Upper left cardiac border: ICS II, linea parasternalis sinistra4. Lower left cardiac border: ICS VI, linea axillaris anterior sinistra
Impression: cardiac border was extended caudolaterally
- Auscultation:1. Heart Rate: 120 bpm, regular2. Intensity of the 1 st and 2 nd heart sound were normal, regular, pansystolic
murmurs (+) grade III/6 at the apex and LLSB
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Lungs :Front
• Inspection : symmetric statically and
dynamically• Palpation : fumbling fremitus for right ↓ = left
↓ at ICS V and lower • Percussion : sonor ↓/ sonor ↓ at ICS V and
lower • Auscultation : vesicular sounds (+ ↓ /+ ↓) at ICS V
and lower , crackles (-/-), rales (+/+) in 1/2 basal areaof the lungs
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Lungs :Back
• Inspection : symmetric statically anddynamically
• Palpation : fumbling fremitus for right ↓ = left↓ started from VT VII
• Percussion : sonor ↓/ sonor ↓ started from VT
VII • Auscultation : vesicular sounds (+ ↓ /+ ↓) started
from VT VII , crackles (-/-), rales (+/+) in 1/2 basal
area of the lungs
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• Abdominal :Inspection : Abdomen wall was symmetric to chest wall
Auscultation : Intestinal sound (+) normal
Palpation : Tenderness (-), liver was palpable 5 cm belowarcus costae dextra
Percussion : Tympanic on all over the abdomen region
• Back : kyphosis (-), lordosis (-), scoliosis (-)
• Extremity :- Upper : edema (+/+) , cold acral (-/-)- Lower : edema (+/+) , cold acral (-/-)
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18/4/2013 UNIT
Hb 10,6 g/dl
HCT 31 %
RBC 3,52 106/µl
WBC 9,8 103/µl
PLT 459 103 /µl
GDS 228 mg/dL
SGOT 18 u/l
SGPT 13 u/l
Albumin 2,6 g/dl
Ureum 142 mg/dL
Creatinin 2,1 mg/dL
Natrium 140 mmol/L
Kalium 5,6 mmol/L
Chlorida 116 mmol/L
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Normal P wavePR interval 0,12 seconds
QRS complex 0,08 seconds
R-R regular, HR 130 bpmNormal T wavePoor R wave V1-4
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CONCLUSIONLAH
Pulmonary edema withbilateral pleural efussion
CTR is difficult to be evaluatedApex is difficult to be evaluatedCardiophrenicus angle is difficult to beevaluatedCardiac waist disappearCostophrenic angle is blunt
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• Anatomic : Peripartum cardiomyopathy•
Functional : CHF NYHA IV• Etiology : Cardiomyopathy• Comorbid : azotemia, hypoalbuminemia,hyperkalemia, hyperglikemia, anemia
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• ICVCU• Half-sitting bedrest• O2 6 lt/mnt NRM•
Infus RL 10 cc/jam• Furosemid Inj loading dose 40 mg IV
followed by 20 mg/8 hours• Morphine Inj. 20 mg titration prn• Spironolakton 25 mg 1-0-0• ISDN 3 x 5 mg• Captopril 3x12,5 mg
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• Fluid balance• Consult pulmonologist to manage the
bilateral pleural effusion• Echocardiography
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Ad Vitam : dubia ad bonam
Ad Sanam : dubia ad bonamAd fungsionam : dubia ad bonam
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