4. Name : Mr. P
Age : 53 y.o
Date of birth : 20-10-1969
Address : Sidrap
MR : 970881
Date of Admission : Sept 9th, 2022
DPJP : dr. MZ
Patient Identity
5. History Taking
Chief complaint: Shortness of breath
Shortness of breath was felt since 4 days before admission, especially during
activity, Dyspneu On Effort (+), Orthopnea (-), PND (-), cough (+) 4 days ago
sputum (+), history of haemoptusis (+) 4 days ago, No Fever. There is no chest
pain nor palpitation, No history of chest pain or palpitation.
History of SoB (+), he was admitted in PJT RSWS on March 2022 with ADHF and
CCS clinical scenario type 2, but not took routine medication afterwards.
History of medication at Balai Paru and got medication of codein and tranexamic
acid.
Coronary Risk Factors:
- History of hypertension (-)
- History of Diabetes mellitus (-)
- History of Smoking (+) 1-2 pack/day, stopped since 30 years ago
- History of heart disease in the family (-)
6. Physical Examination
• Composmentis (E4M6V5)
• BP: 114/89 mmHg, HR : 120 bpm regular, RR : 24 tpm, T:
36.90C, spo2 99 % on nasal cannula 3 lpm
• Conjunctiva not anemic, sclera not icteric
• JVP R+3 cmH2O
• Vesicular breath sound, Rales at basal bilateral, wheezing (-)
• S1/S2 Regular heart sound, mumur hard to evaluate
• Extremity: warm, edema bilateral at lower extremity (+)
7. ECG at Cardiac Center
(09/09/2022)
Sinus Rhythm 125 bpm regular, Axis -37o, P wave 0.08 sec, PR interval 0.16 sec, QRS duration 0.08 sec,
Terminal negative P wave at V1 > 1 mm, Tall R waves in I and AVL, Terminal S wave in II,III,AVF , S in V3 + R
in AVL > 28 mm (Cornell criteria), T inverted lead I, AVL, V5-V6
Conclusion : Sinus tachycardia, HR 125 bpm, reguler, LAD, LAE, LVH, Ischemic lateral wall
15. - Severely abnormal LV systolic function, EF 27.3 %
(TEICH)
- Decreased RV systolic function, TAPSE 1.50 cm
- Akinetic and hypokinetic segmental
- Dilatation all chambers with Eccentric LVH
- Moderate MR
- Moderate TR
- eRAP 15 mmHg (2.3 cm/1.8 cm)
Echocardiography Bedside
09/09/2022
17/03/2022
16. Working Diagnosis
• Congestive Heart Failure NYHA III
• Chronic Coronary Syndrome (Clinical Scenario Type
2, PTP Score 20%, High Probability of CAD. Increase clinical like
hood of CAD with Smooking, Resting ECG Changes, LV
dysfunction)
18. Plan
• Monitor vital signs and hemodynamics
• Monitor urine output and fluid balance
• Antigen swabs
• Move to ward if the swab is negative
• Echocardiography full study
19. Name : Mrs. R
Age : 61 years old
Date of Birth: January 29th 1961
Address : Makassar
MR : 572632
Admission : Sept 9th 2022
DPJP : dr. AFM
2nd Patient Identity
Patient was referred from RSI Faisal with the
diagnoses of Acute lung oedem, Emergency
Hyptertension, Dm type 2
20. History Taking
Chief complaint: Shortness of breath
Shortness of breath had been felt since 1 month and worsened 20 hours before admission.
Dyspneu On Effort (+), Orthopnea (+), PND (+). There was occasional cough accompanied by
phlegm since ± 1 year. Fever (-). The previous history of shortness of breath (+) 1 year ago,
history of being treated and diagnosed with CHF and asthma. No chest pain. No palpitations.
No history of chest pain nor palpitation. History of routine medication: regularly taking
medicine furosemide 40mg, Amlodipine 10mg, and salbutamol inhalation.
- History of Hypertension (+) since 15 years ago
- History of DM(+) since 15 years ago, taking Levemir 16 IU/sc and Trajenta duo (Linagliptin 2.5 mg and
metformin 500 mg)
- No history of heart disease in the family
- Patient was admitted to Faisal Hospital with emergency hypertension, blood pressure at admission
(9/9/2022) was 260/120 mmHg and given NTG 20 mcg/minute/syringe-pump and Furosemide 20
mg/hour/syringe-pump. Patients was also given the Yale protocol, and were discontinued prior to the
referral hospital.
21. Physical Examination
• Composmentis (E4M6V5)
• BP: 150/94 mmHg, HR: 120 bpm, regular, RR: 28 tpm,
T: 36.3 oC, SpO2 95% (on NRM 15 lpm)
• Conjunctiva not anemic, sclera not icteric
• JVP R+3 cmH2O
• Vesicular breath sound, rales (+) at basal bilateral and
wheezing (+) in both hemithorax
• Regular S1/S2 heart sound, murmur was hard to
evaluate
• Extremities: edema bilateral at lower extremity (+),
warm Acral
22. ECG at Faisal Hospital
(09/09/2022)
Sinus Rhythm 136 bpm regular, Axis 60o, P wave 0.04 sec, PR interval 0.16 sec, QRS
duration 0.08 sec, R in V3 < 3mV, Fragmented QRS complex lead II, III, AVF
Conclusion : Sinus tachycardia, HR 136 bpm, reguler, normoaxis, Poor r wave
progression
23. ECG at Cardiac Center
(09/09/2022)
Sinus Rhythm 136 bpm regular, Axis 63o, P wave 0.04 sec, PR interval 0.16 sec, QRS
duration 0.08 sec, R in V3 < 3mV, Fragmented QRS complex lead II, III, AVF
Conclusion : Sinus tachycardia, HR 136 bpm, reguler, Normoaxis, poor R wave
progression
35. Plan
• Monitor hemodynamics and vital signs
• Monitor urine output and fluid balance
• Consult to EMD division
• Consult to Pulmonology department
• Consult to Nephrology division
• PCR Swab
• Move to CVCU care if swab is negative
• Echocardiography full study if the swab is negative
36. Endocrine Metabolic Departement
A/
Diabetic Mellitus Type non obese
Acute Decompensated Heart Failure
Asma Bronkiale
M/
Diet DM 17 kkal
Levemir 0-0-12 IU/SC
P/
Check HbA1C
GDP / days
37. Name : Mr. G
Age : 55 y.o
Date of birth : 02-11-1967
Address : Makassar
MR : 992636
Date of Admission : Sept 9th 2022
DPJP : dr. MZ
3rd Patient Identity
Patient was referred from Mitra Manakarra Hospital,
Mamuju with CHF + pneumonia + nephrolithiasis
38. History Taking
• Chief complaint : Shortness of Breath
• Shortness of breath since 4 days before admission. DoE (+) PND (-) Orthopneu (-). Chest
Pain (-). Palpitation (-) Fever (-) Cough (+) with whitish expectorant. Swelling of extremities
(+) pain (+) VAS 7/10, with inflamed tophus in the fingers, toes and elbows since > 1 month
ago. Ulceration (+) with pus on the right elbow. He was admitted to Mitra Manakarra
hospital due to pain on the elbows 9 days prior referral.
• There was no history palpitation, nausea (+), vomiting (-), loss of appetite (+) general
weakness (+)
Coronary Risk Factor :
• There was no history of Hypertension
• There was no history of Diabetes Mellitus
• There was history of Smoking for 30 years and ceased since 2 years ago
• There was no history of Cardiovascular Disease
• There was history of disease is Gout Arthritis, but left untreated
39. Physical Examination
• Composmentis (E4M6V5)
• BP: 150/90 mmHg, HR : 88 bpm, regular, RR :24 tpm, T: 36.60C,
SpO2 98% room air
• Conjunctiva anemic, sclera not icteric
• JVP R+3 cmH2O
• Vesicular breath sound, Rales at basal bilateral, wheezing (-)
• S1/S2 regular heart sound, no audible murmur
• Extremity: swelling on four extremities with multiple tophus,
ulceration (+) on right elbow, pain (+) warm acral.
49. • Normal LV systolic function, EF 62.7 % (TEICH)
• Normal RV systolic function, TAPSE 2.32 cm
• Global normokinetic
• Normal cardiac chamber and normal cardiac valves
• eRAP 8 mmHg (1.6/0.8)
Echocardiography Bedside
09-09-2022
50. Working Diagnosis
• Congestive Heart Failure NYHA II
• Hypertensive Heart Disease
• Acute on Chronic Kidney Disease G5Ax
• Gout arthritis
• Hypoglycaemia (80)
52. Plan
• Monitoring vital sign and hemodynamic
• Monitor urine output
• Consult to to Nephrology division
• Consult to Rheumatology division
• Glucose check/ 12 hours, monitoring signs of whipple’s triad
• Antigen swabs
• Move to ward if the swab is negative
• Echocardiography full study
• Abdominal Ultrasound
55. Name : Mrs. S
Age : 67 years old
Date of Birth: June 26th 1955
Address : Toraja
MR : 992642
Admission : Sept 09th 2022
DPJP : dr. MZ
4th Patient Identity
56. History Taking
Chief complaint: Shortness of Breath
Shortness of Breath was felt since 4 days before admission to the hospital and
worsened since 1 day. DOE (+) PND (-) Ortopneu (-). Accompanied with swelling
on both legs. There was no previous history of shortness of breath. There was
Cough since 3 weeks with whitish expectorant. Subfebrile fever is present.
No chest pain, previous history of chest pain was denied. No palpitations and
previous history of palpitations.
Coronary Risk Factor :
- History of Hypertension since > 1 year ago, not taking medication regularly
- No Diabetes Mellitus history
- No history of heart disease in the family
70. Plan
• Monitor hemodynamic and vital signs
• Monitor urine output
• Antigen Swabs
• Move to ward if the swab is negative
• Echocardiography full study
• Consult to Pulmonology department
• MSCT scan thorax with contrast
• Blood smear (Monday, 12/9/2022)
71. Name : Mrs. A
Age : 31 years old
Date of Birth: August 9th 1991
Address : Makassar
MR : 979410
Admission : September 10th 2022
DPJP : dr. AFG
5th Patient Identity
72. History Taking
Chief complaint: Shortness of breath
Shortness of breath was felt since 5 days ago, worsening since the last 2 days. Complaints
accompanied by swelling in the legs and abdomen since 4 days. DOE (+), Orthopnea (+), PND (+).
There is history of shortness of breath. No chest pain. There was no history of chest pain. No fever,
no history of fever. Nausea and no vomiting.
Patients with a history of hospitalization at Cardiac Center in September 2022 and was diagnosed
with AF RVR, severe MR, moderate to severe TR, and ADHF.
Medication from policlinics: digoxin 0.25 mg, spironolactone, furosemide 40 mg, VIP albumin,
candesartan 8 mg, and xarelto 20 mg, lansoprazole 30 mg, candesartan 8 mg. The patient was
scheduled for surgical mitral valve replacement.
- No history of hypertension
- No history of diabetes mellitus
- There is no family history of cardiovascular disease
83. -
- Severe Primary MR due to RHD
- Normal LV systolic function, EF 60.3% (TEICH)
- Normal RV systolic function, TAPSE 1.73 cm
- Global normokinetic
- All chambers Dilatation
- Moderate to severe TR with high probability of PH
- eRAP 15 mmHg (2.9/2.6)
Echocardiography Bedside
09/09/2022
26/8/2022
86. Plan
• Monitoring vital signs and
hemodynamics
• Monitor urine output, fluid balance
• Move to ward
• Consult to Cardiothoracic Surgery
department
87. Name : Mr. MA
Age : 64 years old
Date of Birth: 01-09-1968
Address : Makassar
MR : 989710
Admission : September 10th 2022
DPJP : dr. MZ
Patient Identity
88. Chief complain : Shortness of Breating
History taking : (Alloanamnesis)
Sudden shortness of breath was felt since 10 minutes before admission.
Occurred at rest. History of SoB (+) DOE (+) PND (+) Orthopnea (+)
He was frequently admitted to hospital due to SoB, latest was on August
2022 with diagnosis of ADHF, CCS clinical scenario type 2, diabetic
kidney disease G5D, non-obese type 2 DM, normochromic normocytic
anemia, bilateral pleural effusion.
History of routine hemodialysis 3x a week at RSWS, Tuesday-Thursday-
Saturday but the patient skipped 1 dialysis appointment, yesterday
(Thursday), due to having an eye surgery.
Primary Survey
89. Instruction
A Clear, Patent
B RR : 40 x/minutes, spontaneous, abdomino-thoracal, SpO2
90%
O2 nasal cannula 4 lpm
C Cold acral, weak pulse
Physical Examination
Primary Survey (00.25)
While doing the primary survey the patient suddenly
loss consciousness GCS E1M1V1
90. Time SOA Instruction
00.27 S/ unconscious
O/ GCS E1M1V1
Pulseless
Rhythm monitor: pulseless electrical activity
P/
- Code blue activation
- Begin CPR 30:2 and administration of
epinephrine 1 amp q3-5 minutes
00.30 S/ unconscious
O/ GCS E1M1V1
Pulseless
Rhythm monitor: asystole
P/
- Continue CPR 30:2 and administration
of epinephrine 1 amp q3-5 minutes
01.00 S/ unconscious
O/ GCS E1M1V1
Pulseless
Total dilatation of pupils, negative light reflex, negative corneal reflex
Cold acrals
monitor rhythm: asystole
P/
The patient was declared dead at 01.00
in front of the family
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