CHAPTER II CASE REPORT II.1 IDENTIFICATION Name Age Sex Address Status O u!ation #eligion : Mr.

Fa : 63 years old : Male : Jl. Psi lautan lrg. Cemara Kel. 36 ilir Palembang : Married : "abour : $slam

Admitted to %os!ital : &%ursday' O tober (nd ())* II.2 ANAMNESIS (Autoanamnesis dan Alloanamnesis (house i!e"" C%ie+ Com!laint S%ortness o+ breat% so %ea,y sin e - day be+ore admission. .istory o+ illness / -) days be+ore admission' t%e !atient om!lained o+ %a,ing s%ortness o+ breat%' it 0as de!end on !osition' !atient +ell more om+ortable i+ %e sit do0n' and de!end on a ti,ity' %e 0ill s%ortness o+ breat% a+ter go to toilet' !atient 0ould not om!lained it i+ %e 0as ta1e a rest. 2ut no de!end on 0eat%er and not +ollo0ing o+ 3ngi13 ,oi e. .e 0ill be more om+ortable 0it% ( 4 3 !illo0s 0%en slee! time. .e denies any om!laint 0a1e u! in slee! time 0it% s%ortness o+ breat% and %est !ain. .e also denies any om!laint o+ %eart !al!itation' oug%' +e,er' or o,er s0eating during nig%t time. .e also 0as om!laint s0ell in bot% o+ lo0er extremity. S0elling in !al!ebra su!erior 0as denied. .e 0as om!laint i teri in s1in and eyes. .e %as no om!laint nausea and ,omitting. &%ere 0as disorder in urinate' turn yello0 tea urine' but no disorder in de+e ation. / - day be+ore admission' t%e !atient om!lained o+ %a,ing s%ortness o+ breat% so %ea,y' it 0as de!end on !osition' !atient +ell more om+ortable i+ %e sit

do0n' and de!end on a ti,ity' !atient 0ould not om!lained it i+ %e 0as ta1e a rest. 2ut no de!end on 0eat%er and not +ollo0ing o+ 3ngi13 ,oi e. .e 0ill be more om+ortable 0it% ( 4 3 !illo0s 0%en slee! time. .e denies any om!laint 0a1e u! in slee! time 0it% s%ortness o+ breat% and %est !ain. .e also denies any om!laint o+ %eart !al!itation' oug%' +e,er' or o,er s0eating during nig%t time. .e also 0as om!laint s0ell in bot% o+ lo0er extremity. S0elling in !al!ebra su!erior 0as denied. .e 0as om!laint i teri in eyes' yello0 s1in 0as denied. .e %as no om!laint nausea and ,omitting. &%ere 0as no disorder in urinate and de+e ation. 5 5 5 5 5 .istory o+ !ast illness .istory o+ %eart disease sin e / - years ago and %as admitted to %os!ital -( times. .istory o+ %y!ertension sin e / - years ago' un ontrolled. .istory o+ diabetes mellitus 0as denied .istory o+ 1idney disease 0as denied .istory o+ tuber ulosis 0as denied Family 6isease .istory .istory o+ t%e same sym!toms in %is +amily 0as denied. II.# PH$SICA% E&AMINATION 7eneral examination -. (. 3. 8. 9. 6. <. 7eneral ondition Cons iousness 2lood !ressure Pulse rate #es!iration rate &em!erature : si 1 : om!os mentis : -9):;) mm.g : *) times:minute' reguler : (* times:minute : 36'9) C Si 1ness ondition : moderate si 1ness

*. ;. -). --.

6e%ydration Nutrition ?eig%t .eig%t : 9* 1g

: =5> : #2? @ ---A $m!ressi,e: O,ernutrition : -9* m

S!esi+i examination -. S1in S1in olor is !u e Normal !igmentation B+lores ense' i teri ' sianoti or !ale on !alm and !lantar =5> S ar =5> .y!er%idrosis =5> Normal %air gro0t% 7ood turgor Bnoug% +at layer ?et or dry in !al!itation =5> Nodul sub utan =5> (. "ym!% gland &%ere 0ere no enlargment o+ t%e lym!% nodes on submandibular' ne 1' axillaries and inguinal. 3. .ead O,al' symmetri al Pu++y +a e =5> 6e+ormity =5> Malar ras% =5>

 8. Bye

Alo!e ia =5>

B1so!%talmus and eno!%talmus =5> Bdematous !al!ebra su!erior =5> Pale o+ onCun ti,a !al!ebra =5> S lera i teri =D> 9. Nose B!istaxis =5> Normal nasal se!tum Normal mu ous layer 6. Bar 7ood %earing Normal bot% o+ meatus a usti us externus <. Mout% #%agaden o+ li!s =5> Stomatitis =5> Pa!il atro!%y =5> 7um bleeding =5> Fetor oris =5> *. Ne 1 &%yroid gland not !al!able' t%yroid bruit =5> Jugular ,ein !ressure =9D(> m.() .y!ertro!%y o+ mus ulus sterno leidomastoideus =5>' sti++ness =5>

;. &%orax Normal s%a!e Bxtended inter ostal se tion =5> #etra tion =5> Eene tasis =5> S!ider ne,i =5>

-). "ung Anterior o+ t%e lung $ns!e tion Pal!ation Per ussion : symetri al o+ stati and dynami rig%t and le+t are eFual : #ig%t and le+t lung stem+remitus are eFual : sonor on le+t and rig%t lung

Aus ultation : ,esi ular =D> normal' so+t 0et rales on t%e base o+ le+t and rig%t lung' 0%eeGing =5>

Posterior o+ t%e lung $ns!e tion Pal!ation Per ussion : symetri al o+ stati and dynami rig%t and le+t are eFual : #ig%t and le+t lung stem+remitus are eFual : sonor on le+t and rig%t lung

<

Aus ultation : ,esi ular =D> normal' so+t 0et rales on t%e base o+ le+t and rig%t lung' 0%eeGing =5>

--. Cor $ns!e tion Pal!ation Per ussion Aus ultation : i tus ordis 0as seen in $CS E : i tus ordis 0as !al!able in $CS E : u!!er boundary o+ or is $CS $$$' le+t boundary o+ or is "AA and rig%t boundary o+ or is "MC dextra. : %eart rate : *) times:minutes' regular' murmur =D> Sistoli1 on mitral and tri us!id ,al,e' gallo! =5> -(. Abdomen $ns!e tion Pal!ation : +lat' ,ene tation =5>' : no !ain in !al!ation' s!leen is un!al!able' li,er is !al!able 3 +ingers under ar us ostae Per ussion : tym!any' s%i+ting dullness =5>

Aus ultation : bo0el sound =D> normal

-3. Bxternal genitalia : not examined

-8. H!!er extremity Pain on Coint =5> Pale on +inger =5> Bryt%ema o+ !alm =5> Pitting edema =5> Clubbing +inger =5> &remor =5> Normal !%ysiologi al re+lex

-9. "o0er extremity Eari es =5> Minimal edema =D> Pain on Coint =5> Pale on +inger =5> Normal !%ysiologi al re+lex

II.' ADDITIONA% E&AMINATION Ble tro ardiogra!%y =( o tober ())*> AF dan axis 0as normal' .# @ *; times:minute' P 0a,e inestimable' I#S om!lex@ )')* se onds' #:S E- J-' SE- D #E9:E6 J39' I !at% E3 4 E9. $m!ressi,e: AF D OM$ lateral. "aboratory Findings =( o tober ())*> 2lood analysis .emoglobin .emato rite "eu1o yte : --'; g:dl : 39 ,olA : 6.-)):mmK = N: -85-* g:dl > = N: 8)58* ,olA > = N: 9)))5-)))): mmK >

 BS# &rombo yte 6i++. Count 2SS C%olesterol total .6"5 %olesterol "6"5 %olesterol &rigly erida Hreum Creatinin Sodium Potassium

: -* mm:%r : -)-.))) : ):(:):<):(6:(L

= N: J -) mm:%r > = N: ()))))59))))): mmK >

= N: )5-:-53:(56:9)5<):()58):(5* > : -3( mg:dl : -(- mg:dl : (3 mg:dl : *( mg:dl : <; mg:dl : (8 mg:dl : -'( mg:dl : -39 mmol:l : 3'3 mmol:l = N: J ()) > = N: M 99 > = N: J-3) > = N: J -9) > = N: -953; > = N: )';5-'3 > = N: -395-99 mmol:l > = N: 3'959'9 >

#ontgen t%orax =6 o tober ())*> $m!ressi,e: ardiomegaly and ongesti,e !ulmonum Ad,ise: HS7 o+ ardia .

II.( RES)ME A man 0%o %as initial name Mr. Fa' 63 years old' admitted to %os!ital in &%ursday' (nd o tober ())*' 0it% %ie+ om!laint s%ortness o+ breat% so %ea,y sin e day be+ore admission. / -) days be+ore admission' t%e !atient om!lained o+ %a,ing s%ortness o+ breat%' it 0as de!end on !osition' !atient +ell more om+ortable i+ %e sit do0n' and de!end on a ti,ity' %e 0ill s%ortness o+ breat% a+ter go to toilet' %e 0ould not om!lained it i+ %e 0as ta1e a rest. .e 0ill be more om+ortable 0it% ( 4 3 !illo0s 0%en slee! time. .e also 0as om!laint s0ell in bot% o+ lo0er extremity. .e 0as

-)

om!laint i teri in s1in and eyes. &%ere 0as disorder in urinate' turn yello0 tea urine. / - day be+ore admission' t%e !atient om!lained o+ %a,ing s%ortness o+ breat% so %ea,y' it 0as de!end on !osition' !atient +ell more om+ortable i+ %e sit do0n' and de!end on a ti,ity' !atient 0ould not om!lained it i+ %e 0as ta1e a rest. .e 0ill be more om+ortable 0it% ( 4 3 !illo0s 0%en slee! time. .e also 0as om!laint s0ell in bot% o+ lo0er extremity %as more less. .e 0as om!laint i teri in eyes. &%e !atient %as %istory o+ %eart disease sin e / - years ago and %as admitted to %os!ital -( times and %istory o+ %y!ertension sin e / - years ago' but un ontrolled. From !%ysi al examination got general ondition o+ t%e !atient 0as si 1' si 1ness ondition 0as moderate si 1ness and %is ons iousness 0as om!os mentis. 2lood !ressure -9):;) mm.g' !ulse rate *) times:minute' reguler' res!iration rate (* times:minute' tem!erature 36'9) C' #2? =0eig%t @ 9* 1g and %eig%t @ -9* m> @ ---A' im!ressi,e o,ernutrition. From examination got s lera i teri ' Cugular ,ein !ressure =9D(> m.(O. $n anterior and !osterior o+ lung examination' got so+t 0et rales on t%e base o+ le+t and lung' 0%ile in or examination got i tus ordis 0as seen in $CS E and !al!able in $CS E' on !er ussion got u!!er boundary o+ or is $CS $$$' le+t boundary o+ or is "AA and rig%t boundary o+ or is "MC dextra' and on aus ultation got %eart rate *) times:minutes' regular' murmur =D> sistoli1 on mitral and tri us!id ,al,e' gallo! =5>. ?%ile abdomen examination' li,er is !al!able 3 +ingers under ar us ostae and lo0er extremity got minimal edema. S ore Framing%am +or t%is !atient are MaCor Criteria N Paro1sysmal no tunal dis!neu N 6istension o+ ne 1 ,ein N #ales on !ulmo N Cardiomegali N Bdema !ulmonal a ute =D>:=5> =5> =5> =D> =D> =D>

--

N 7allo! S3 N $n reasing JEP N #e+lu1s %e!atoCugular Minor Criteria N Bdema o+ extremity N Coug% in nig%t time N 6is!nea dOe++ort N .e!atomegaly N Pleural e++usion N 6e rease ,ital a!a ity N &a i ardia =M-() times:minute> II.* +OR,IN- DIA-NOSIS

=5> =D> =D>

=D> =5> =D> =D> =5> =5> =5>

C%roni %eart +ailure e. M$ 4 MS D %y!ertension stage II.. DIFFERENTIA% DIA-NOSIS C%roni %eart +ailure e. ..6 D %y!ertension stage C%roni %eart +ailure e. C.6 D %y!ertension stage -

II./ TREATMENT Non!%arma %ology 2edrest Cor diet $E .al+ sitted !osition

P%arma %ology $EF6 69 gtt P:minute:mi ro Furosemide am! -x-

-(

Ca!to!ril tab 3x(9 mg S!ironola tone tab -x(9 mg A etosal tab -x-)) mg Ome!raGole tab -x"axadyn syr 3x-C KS# -x-

II.0 P%ANNIN B %o ardiogra!%y HS7 o+ ardia .

II.11 PRO-NOSIS 6ubia II.11 FO%%O+ )P For general examination' !atient is %a,ing unstable blood !ressure. First day' blood !ressure is -9):;) mm.g' se ond day is -3):*) mm.g' t%ird day is -8):;) mm.g' and +ourt% and +i+t% day are -<):;) mm.g and -8):-;) mm.g. Hntil +our days a+ter admitted to %os!ital' t%e !%ysi al examination o+ t%is !atient is still same' s lera i teri ' Cugular ,ein !ressure =9D(> m.(O. $n anterior and !osterior o+ lung examination' got so+t 0et rales on t%e base o+ le+t and lung' 0%ile in or examination got i tus ordis 0as seen in $CS E and !al!able in $CS E' on !er ussion got u!!er boundary o+ or is $CS $$$' le+t boundary o+ or is "AA and rig%t boundary o+ or is "MC dextra' and on aus ultation got %eart rate *) times:minutes' regular' murmur =D> sistoli1 on mitral and tri us!id ,al,e' gallo! =5>. ?%ile abdomen examination' li,er is !al!able 3 +ingers under ar us ostae and lo0er extremity got minimal edema. 2ut in +i,e days a+ter admission' t%e !atient %as been losed o+ edema !retibial. &%e t%era!y +or t%is !atient is still t%e same +rom t%e +irst day admitted to t%e %os!ital until +i+t% day o+ admission. For !lanning' regularly ele trolite examination.

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CHAPTER III CASE ANA%$SIS $n t%is ase'a man' 63 years old' residen es at Palembang ity' 0as admitted to dr. Mo%ammad .oesin %os!ital sin e O tober (nd' ())*. Patient ame 0it% %ie+ om!lain s%ortness o+ breat% so %ea,y sin e day be+ore admitted to %os!ital. From t%e %istory o+ illness' about -) days be+ore admission' t%e !atient om!lained o+ %a,ing s%ortness o+ breat%' it 0as de!end on !osition' !atient +ell more om+ortable i+ %e sit do0n' and de!end on a ti,ity' %e 0ill s%ortness o+ breat% a+ter go to toilet' !atient 0ould not om!lained it i+ %e 0as ta1e a rest. 2ut no de!end on 0eat%er and not +ollo0ing o+ 3ngi13 ,oi e. .e 0ill be more om+ortable 0it% ( 4 3 !illo0s 0%en slee! time. .e denies any om!laint 0a1e u! in slee! time 0it% s%ortness o+ breat% and %est !ain. .e also denies any om!laint o+ %eart !al!itation' oug%' +e,er' or o,er s0eating during nig%t time. .e also 0as om!laint edema in bot% o+ lo0er extremity. Bdematous in !al!ebra su!erior 0as denied. .e 0as om!laint i teri in s1in and eyes. .e %as no om!laint nausea and ,omitting. &%ere 0as disorder in urinate' turn yello0 tea urine' but no disorder in de+e ation. / - day be+ore admission' t%e !atient om!lained o+ %a,ing s%ortness o+ breat% so %ea,y' it 0as de!end on !osition' !atient +ell more om+ortable i+ %e sit do0n' and de!end on a ti,ity' !atient 0ould not om!lained it i+ %e 0as ta1e a rest.

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2ut no de!end on 0eat%er and not +ollo0ing o+ 3ngi13 ,oi e. .e 0ill be more om+ortable 0it% ( 4 3 !illo0s 0%en slee! time. .e denies any om!laint 0a1e u! in slee! time 0it% s%ortness o+ breat% and %est !ain. .e also denies any om!laint o+ %eart !al!itation' oug%' +e,er' or o,er s0eating during nig%t time. .e also 0as om!laint edema in bot% o+ lo0er extremity. Bdematous in !al!ebra su!erior 0as denied. .e 0as om!laint i teri in eyes' yello0 s1in 0as denied. .e %as no om!laint nausea and ,omitting. &%ere 0as no disorder in urinate and de+e ation. From t%is anamnesis' t%ere 0ere s%ortness o+ breat% sin e about -) days be+ore admission' more om+ortable 0it% ( 4 3 !illo0s 0%en slee! time and edema in bot% o+ lo0er extremity. &%is onditions s%o0 lini al sym!toms 0%i % indi ates %eart +ailure. S%ortness o+ breat% is sym!tom +or le+t side o+ %eart +ailure' !atient is o+ten measured in t%e number o+ !illo0s reFuired to lie om+ortably. S%ortness o+ breat% %a!!ened be ause edema 0%i % o ur in t%e lungs be ause le+t side =le+t ,entri le> o+ %eart +ailure ause ongestion o+ t%e !ulmonary ,as ulature' and so t%e sym!toms are !redominantly res!iratory in nature. &%is redu es s!are a!a ity +or ,entilation' auses sti++ening o+ t%e lungs and redu es t%e e++i ien y o+ gas ex %ange by in reasing t%e distan e bet0een t%e air and t%e blood<. &%e ot%er mean o+ s%ortness o+ breat% is es!e ial sym!tom +or mitral stenosis. $t ondition an aused by in rease o+ blood +lo0 t%roug% mitral or time de rease o+ diastole +illing *. Bdema in bot% o+ lo0er extremity is sym!tom +or rig%t sided o+ %eart +ailure. Failure o+ t%e rig%t ,entri le leads to ongestion o+ systemi a!illaries. &%is %el!s to generate ex ess +luid a umulation in t%e body. &%is auses s0elling under t%e s1in =termed !eri!%eral edema or anasar a> and usually a++e ts t%e de!endent !arts o+ t%e body +irst = ausing +oot and an1le s0elling in !eo!le 0%o are standing u!' and sa ral edema in !eo!le 0%o are !redominantly lying do0n>. $n t%e !ast %istory' t%ere 0as %istory o+ %eart disease sin e / - years ago and %as admitted to %os!ital -( times and %istory o+ %y!ertension sin e / - years ago but un ontrolled. .eart +ailure an aused by oronary artery disease' %ig% blood !ressure =%y!ertension>' %eart atta 1' diabetes' ardiomyo!at%y' %eart ,al,e disease =e.g.' ,al,ular stenosis or ,al,ular regurgitation>' in+e tion in t%e %eart ,al,es

-9

=,al,ular endo arditis> or o+ t%e %eart mus le =myo arditis>' ongenital %eart disease = ardia onditions !resent sin e birt%>' se,ere lung disease =e.g.' !ulmonary From general examination' blood !ressure -9):*) mm.g' !ulse rate *) times:minute' reguler' res!iration rate (* times:minute' and tem!erature 36'9) C. On t%e measuring o+ body %eig%t -9* m and body 0eig%t 9* 1g' t%is !atient is o,ernutrition. From t%e !%ysi al examination' t%ere 0as an in reasing Cugular ,ein !ressure =9D(> m.(O. $n reasing o+ JEP is mean t%at t%ere 0ere rig%t side o+ %eart +ailure-). Cugular ,ein !ressure is +reFuently assessed as a mar1er o+ +luid status' 0%i % an be a entuated by t%e %e!atoCugular re+lux. On !ulmonal examination' so+t 0et rales on t%e base le+t and rig%t !ulmo. $n %eart examination' i tus ordis an be seen and !al!able at $CS E' %eart is enlarged 0it% u!!er boundary is $CS $$$' le+t boundary is "AA sinistra and rig%t boundary is "MC dextra. ?it% aus ultation' t%ere 0as sistoli murmur on mitral and tri us!id ,al,e. Sistoli murmur is es!e ial sign o+ mitral insu+isiensi. Magni+i ation o+ %eart is om!ensation o+ ongesti,e o+ %eart +ailure*. $n abdomen examination' li,er 0as !al!able 3 +ingers under ar us ostae. $t mean t%at t%ere 0ere signi+i ant li,er ongestion may result in im!aired li,er +un tion' and 0e an loo1 at eyes examination' t%ere 0as s lera i teri . Ot%er' 0e got minimal edema !retibial' it ause ex ess +luid a umulation in t%e body. On additional examination' +rom laboratory +indings' t%ere 0ere de reasing %emoglobin =--'; g:dl>' %emato rite =39 ,olA>' trombo yte =-)-.))):mmK > and lo0 .6" =(3 mg:dl> and de reasing !otassium =3'3 mmol:l>. BS# and di++ ount is normally' it mean t%at no %roni disease. 2SS measure is su!!osed to 1no0 0%et%er t%is !atient %as diabetes mellitus or not' be ause !atient 0it% diabetes mellitus an be ause o+ ongesti,e %eart +ailure' but in t%is !atient' 2SS is -3( mg:dl 0%i % s%o0 t%at %is blood glu ose is normal. Patient 0it% edema 0ill be ta1e diureti ' so ele trolite rate must be 1no0n and 0at %. $n t%is !atient' sodium is normal =-39 mmol:l> but !otassium 0as de rease =3'3 mmol:l>' so t%at 0e must be 0at %. %y!ertension> or obstru ti,e slee! a!nea' !eri ardial disease =!eri arditis> and et .;

-6

On radiologi al +inding s%o0s t%ere 0as magniti+i ation o+ or' to rig%t and to le+t' !ulmo s%o0 ranialisation and also Kerley line. Kerley line means t%ere 0as edema intersitial 0%i % es!e ial sign +or edema !ulmonal and t%ere 0as in radiologi al mitral stenosis. On ele tro ardiogra!%y' AF dan axis 0as normal' .# @ *; times:minute' P 0a,e inestimable' I#S om!lex@ )')* se onds' #:S E- J-' SED #E9:E6 J39' I !at% E3 4 E9' im!ressi,e AF D OM$ lateral. AF ondition dete table in mitral insu+isiensi and also I !at% an be got in mitral insu+isiensi aused by is %emi. From anamnesis' !%ysi al examination' and also additional examination' it an be on luded 0or1ing diagnosis ongesti,e %eart +ailure et ausa mitral insu+isiensi 4 mitral stenosis D %y!ertension stage $' 0%i % di++erentiated diagnose 0it% ongesti,e %eart +ailure et ausa %y!ertension %eart disease D %y!ertension stage $ and ongesti,e %eart +ailure et ausa oronary %eart disease D %y!ertension stage $. &reatment +or t%is !atient are bedrest' or diet $E' %al+ sitted !osition +or non!%arma %ology' $EF6 69 gtt P:minute:mi ro' +urosemide am! -x-' a!to!ril tab 3x(9 mg' s!ironola tone tab -x(9 mg' a etosal tab -x-)) mg' ome!raGole tab -x-' laxadyn syr 3x-C and KS# -x- +or !%arma %ology. Prognosis +or ongesti,e %eart +ailure determined by ardia status-). +or t%is !atient' 0e Cust !rognosis dubia at t%e same time 0e +ollo0 u! %is ardia status.

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