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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