Lapsus Cardio v3

7/30/2019 Lapsus Cardio v3

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Nurfitrianti (c11109300)

Supervisor:dr. Muzakkir Amir, Sp.JP, FIHA, FICA

PULMONARY EMBOLISM + CHF NYHA IV ecHHD + PH SEVERE


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PATIENT IDENTITY

Name : Ms.N

Gender : Female

Age : 53 years oldAddress : Enrekang

Registration number : 615504

Date of admission : 26th July 2013


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HISTORY TAKING Chief complain : Unconsciousness Present illness history:

Patient was unconscious 2 hours before admitted toWahidin Sudirohusodo Hospital. Unconsciousness wasoccur suddenly, and accompanied with shortness of

breath, bluish color on lips and extremities. History ofadmitted in PCC Hospital with swelling on lowerextremities, shortness of breath, and cough with whitesputum, and diagnosed with Congestive Heart Failure. 2hours before, patient suddenly unconscious, withshortness of breath, and bluish color on lips and lower

extremities. And referred to Wahidin SudirohusodoHospital for further treatment. According to family, patientslept with 2-3 pillows during sleeping for 6 months andbreathlessness in walking far distance. Since than patientdo little activity and only eat and sleep in her house. Nochest pain, palpitation, fever, nausea, and vomiting.

Urination and defecation was normal


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Previous illness history:

- History of admitted in PCC Hospital on July 26th

2013 with swelling lower extremities and shortnessof breath. Diagnosed as CHF

- History of hypertension for 7 years, with highestblood pressure of systolic 240 mmHg. With irregulartreatment.

- History of heart disease for long time.

- No history of Diabetes Mellitus


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Physical Examination General Status :

Moderate-illness/obese/unconscious

Vital Sign :

Blood Pressure : 140/90 mmHg

Pulse : 84 bpm, regular

Respiratory rate : 29 tpm

Body temperature : 36,5 C BMI : 32,4kg/m2


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Head Examination

Eyes : anemic -/-, icterus -/- Lip : cyanosis (+) Neck : JVP R +1 cmH2O,

lymphadenopathy (-)

Chest Examination

Inspection : symmetric R=L, normochest Palpation : mass (-), tenderness (-)

Percussion : sonor Auscultation :

breath sound : vesicularadditional sound : ronchi -/-

wheezing -/-


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Cardiac Examination

Inspection : Ictus cordis wasntvisible

Palpation : Ictus cordis wasntpalpable

Percussion :- Right border : right parasternalis line- Left border : 1 finger to the lateral

of left midclavicular line

Auscultation : Regular of I/II heart sound


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Abdominal Examination

- Inspection : flat and following breath movement- Auscultation : peristaltic sound (+) , normal- Palpation : liver and spleen unpalpable- Percussion : tympani, ascites (-)

Extremities- Edema : Pretibial +/+ and dorsum pedis


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LABORATORIUM FINDINGSTest Result Normal value

WBC 6,35 x 106 4,0-10,0 x 103

HGB 13,9 13,0-17,0 g/dl

HCT 47 40,0-54,0 %

PLT 218 150-500 x 103

RBC 6,29 4-6 x 106

Ureum 23 10-50 md/dL

Creatinin 1,1


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LABORATORIUM FINDINGSTest Result Normal value

Na 123 136-145 mmol

K 3,2 3,5-5,1 mmol

Cl 81 97-111 mmol

Albumin 3,4 3,5-5,5 g/dLPT 16,3 control 11,7 10-14 second

APTT 95,6 control 27,0 22-30 second

GDS 294 140 200 mg/dL

CK 41 L(


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Analysis blood gases

Test Result Normal value

pH 7,32 7,35-7,45

pCO2 74,8 mmHg

SO2 91,6

PO2 51,5 80-100 mmHg

HCO3 30,0 22-26


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ECG (29/07/13)


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ECG interpretation- Rhythm : Sinus rhythm- HR/QRS rate : 75 bpm, rreguler

- Axis : Right axis deviation

- P wave : 0,12 s- PR interval : 0,2 s

- QRS complex : 0,08 s, V5 R/S


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Conclusion:

Sinus rhythm, HR 75 bpm, right axis deviation,biatrial hypertrophy, right ventricular hypertrophy,inferior wall ischemic and injury.


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CHEST X-RAY

Cardiomegaly with pulmonary edema


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DIAGNOSISSuspect pulmonary embolismCHF NYHA IV ec HHD

PH severe

Elektrolyte imbalanceHyperglycemia

CAP


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INITIAL MANAGEMENT O2 10 L/minute (via NRM) IVFD NaCl 0,9% 500 cc/24 jam Heart diet Heparin 5000 IU bolus/IV Heparin 1000 IU/jam/IVAspirin (Aspilet) 1x80 mg Clopidogrel (Plavix) 1x75 mg

Furosemide inj 2 A/12jm/IV Dobutamin 5 mikro/SP Tapp off Ceftriaxone inj 2 gr/24 jam/IV (Skin test)


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PULMONARY EMBOLISM

Discussion


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DEFENITION

Pulmonary embolism is a clinically significantobstruction of part or all of the pulmanaryvascular tree, usually caused by thrombus from a

distant site.


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ETIOLOGY

The causes for pulmonary embolism are multifactorialand are not readily apparent in many cases. Thecauses described in the literature include thefollowing:

Venous stasis Hypercoagulable states

Immobilization

Surgery and trauma

Pregnancy

Oral contraceptives and estrogen replacement

Malignancy

Hereditary factors Acute medical illness


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RISK

FACTORS

MAJOR Surgery Major abdominal/pelvic surgeryOrthopaedic surgery (especiallylower limb)Post-operative intensive care

Obstetrics Late pregnancy (higher incidencewith multiple births)Caesarean sectionPre-eclampsia

Malignancy Pelvic/abdominalMetastatic/advanced

Lower limb problems Fracture, varicose veins

Reduced mobility HospitalizationInstitutional care


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MINOR Cardiovascular Congenital heart diseaseCongestive cardiac failureHypertensionCentral venous access

Superficial venousthrombosis

Oestrogens Oral contraceptive pill(especially third-generationhigher oestrogencontaining)Hormone replacementtherapy

Miscellaneous Occult malignancyNeurological disability

Thrombotic disordersObesityInflammatory boweldiseaseNephrotic syndromeDialysis

Myeloprofilerativedisorders


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Pathophysiology

Decrease in blood flow below a certain criticallevel.

Increase in coagulability of blood. Damage of the vessel wall.


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Pathophysiology


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Symptoms and signs

- Symptoms: - Signs:

Shock Cyanosis

Dyspneu TachypneuPleuritic pain Rales

Anterior chest pain Tachycardia

Cough S4

Hemoptysis Accentuated P2

Asymptomatic


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Clinical probability scoringsystem

- Raised respiratory rate- Haemoptysis

- Pleuritic chest pain

Plus 2 other factors:1. Absence of another reasonable clinicalexplanation

2. Presence of a major risk factor

a) plus 1 and 2: HIGH pre-test clinical probabilityb) plus 1 or 2: INTERMEDIATE pre-test clinical

probability

c) alone: LOW pre-test clinical probability.

W ll C it i


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Wells Criteria

Clinical Signs and Symptoms of DVT?

(Calf tenderness, swelling >3cm, errythema, pittingedema affected leg only)

+3

PE Is #1 Diagnosis, or Equally Likely +3

Heart Rate > 100 +1.5

Immobilization at least 3 days, or Surgery in thePrevious 4 weeks

+1.5

Previous, objectively diagnosed PE or DVT? +1.5

Hemoptysis +1

Malignancy w/ Rx within 6 mo, or palliative? +1

>6: High Risk

2 to 6: Moderate Risk

2 or less: LowAdapted with permission from Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, et al. Derivation of a simple

clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED d-dimer.Thromb Haemost 2000;83:416-20.


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Diagnostic testArterial blood gases Cardiac Enzymes: Troponin D-dimer EKG CXR Ultrasound Echocardiography

Angiography


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Management Respiratory Support: Oxygen, intubationAnticoagulation

Thrombolysis

Embolectomy


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THANK YOU

Lapsus Cardio v3

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