A 65 y/o man with Congestive Heart Failure

Angelia Elisabeth Mambu 030.09.019

MEDICAL FACULTY OF TRISAKTI UNIVERSITY RSUD KARAWANG

Identity
Name Age Sex Address Ocupation
Religion Mr. Nurhadi 62 y/o Male Jl.Citarum no 29 Tunggakjati, Karawang Barat Moeslim Married High School Sundanese 14th June 2013

Marital Status Education Ethnic Admitted

Chief Complain Additional Complain

Shortness of breath since 2 days before hopitalized

Fatigue Swelling in both feet Cough Lack of sleep

History of Present Illness

The patient came to Emergency Unit of Karawang Hospital with complaint of shortness of breath since 3 months before hospitalized. The symptom felt worsening and appeared when he is in rush and during her normal activities such as sweeping . To relief the symptom he is using 2 - 3 pillows when sleeping. She always suddenly woken up when she is sleeping because of breathlessness. He also complains about his swelling feet which getting worse from day to day. She denied having a chest pain, fever, nausea and vomit but suffered a bit of cough and exhausted.

History of Past illness

Hypertension (+) Diabetes Melitus (+)

Asthma (-)

History of Family Illness

History of Family Illness Personal and Sosial History

Same disease (-) Hypertension (+) Diabetes Melitus (+) Asthma (-)

Smoking (-) Alcohol (-) Exercise regularly (-) Consume Hypertension drugs and DM drugs regularly

Physical Examination

General Condition
General appearance
Moderately ill
Blood Preasure 150/90 Heart Rate 96 x/min

Vital Sign

Consciousness
Compos mentis
Respiration Rate 24 x/min Temperature 36oC

Head Eyes Neck

Normochepaly, black hair, good distribution

Anemic conjungtiva -/ Icteric sclera -/-

Thyroid gland & lymph nodes enlargement are not palpable JVP : (5+4) cmH2O

Thorax - Heart
Inspection
Ictus cordis is visible

Palpation
Ictus cordis is palpable at 6th ICS 3 cm lateral LMCS

Percussion
Enlargement of the heart, shifting left border of the heart

Auscultation
Regular I II heart sound. No murmur and gallop

Thorax - Lung
Inspection Palpation Percussion Auscultation
Symmetrical Equal vocal resonance Sonor in both lungs Vesicular, Ronchi (+/+) at base both lungs, Wheezing (-/-)

Abdomen
Inspection Auscultation Palpation Percussion
brown skin, symetrical

Bowel sound (+)

Turgor normal, muscular defense (-), mass (-), hepar and lien enlargement (-)

Tympanic, no pain present on abdominal pecussion, Shifting dullness (-)

Ekstremity
Warm Acrals Edema

+ +

+ +

Laboratory test (14th June 2013)

Result Hb Leukosit Trombosit Hematocrit 12,3 7.990 193.000 35 Normal 12 17 g% 5000 10000 150rb 450rb 37 48 %

GDS
Ureum Creatinin Na K Cl CK-MB

45
48,6 1,52 136 4,6 106 22

80 140 mg/dl
10 45 mg/dl 0,4 1,5 mg/dl 134 145 mmol/L 3,5 5,6 mmol/L 100 110 mmol/L < 24 U/l

Laboratory test

16th June 2013

GDS = 248

18th June 2013

GDS = 190

ECG old MCI anterior

Thorax foto AP
CTR > 50% Enlargement of Left Ventricle (LVH) Enlargement of Left Atrium (LAH) Right costophrenicus angle is blunt

Pleura efusion dextra

Echocardiography
Dimensi ruang jantung : LA dilated LVH (+) konsentrik, EPSS 0,92 cm Kontraktilitas LV baik, EF 55% Kontraktilitas RV baik, TAPSE 2 cm Analisa segmental : hipokinetik ringan inferior wall Katup: Ao 3 cupis, kalsifikasi (+), AR trivial, MR mild, TR mild, PR mild Doppler : E/A > 1, Ao V max 1,1 m/s. mPaP 20 mmHg KESIMPULAN
CAD, LA dilated

Fungsi sistolik LV baik, EF 55%

LVH (+) konsentrik AR trivial, MR mild, TR mild, PR mild

Working Diagnosis
CHF NYHA II et causa CAD and Hipoglycemia in Diabetes Melitus tipe II

Diferential Diagnosis
CHF NYHA II e.c HHD CHF NYHA II e.c Cardiomiopathy

Treatment
IVFD Dextrose 10 % Furosemide 2 x 1 Tromboaspilet 1 x 1 ISDN 5mg 3 x 1 CPG 1 x 1 Adalat oros 1 x 1 Irbedox 1 x 1 Bisoprolol 1 x Novomix 12 - 0 - 12

Prognosis
Ad vitam

Dubia ad bonam

Dubia ad Ad Sanationam malam Dubia ad Ad Fungsionam malam

CHF
Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to deliver oxygen rich blood to the body.

Etiology
The most common causes of congestive heart failure are: coronary artery disease high blood pressure (hypertension) longstanding alcohol abuse disorders of the heart valves unknown (idiopathic) causes, such as after recovery from myocarditis

Symptoms
Cough Fatigue, weakness, faintness Loss of appetite Need to urinate at night palpitations Shortness of breath when you are active or after you lie down Swollen (enlarged) liver or abdomen Swollen feet and ankles Waking up from sleep after a couple of hours due to shortness of breath

Diagnosed
Framingham Criteria for Congestive Heart Failure . Mayor Minor
Paroxysmal nocturnal dyspnea Neck vein distention Rales Radiographic cardiomegaly Acute pulmonary edema S3 gallop Increased Jugularis Vena Pressure Hepatojugular reflux Bilateral ankle edema Nocturnal cough Dyspnea on ordinary exertion Hepatomegaly Pleural effusion Decrease in vital capacity by one third from maximum recorded Tachycardia (heart rate>120 beats/min.)

Framingham Criteria for Congestive Heart Failure

Diagnosis of CHF requires the simultaneous presence of at least

2 major

1 major 2 minor

NYHA Classification - The Stages of Heart Failure

Class I Class II Class III

Class IV

No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath).

Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.

Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.

Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

Treatment
Farmachologist

Diet Exercise

Non Farmachologist

Ace inhibitor Beta blocker Diuretic Digoxyn