Cor Pulmonal Chronic

Yanis Indiana Yacma

Preceptor :

dr. Nurkhalis, Sp.JP-FIHA

Case report الله بسمالرحيم الرحمن

Laporan KasusName : Tn.RSex : Man

Age : 31 years oldReligion : IslamEthnic : AcehAdress : PidieOccupation : -No. RM : 1051747Date on arrival : 12 Mei 2015Date on examination: 5 Juni 2015

Anamnesis Chief complaint: Dyspneu

Weak, cough, fever, chest pain

Current medical history: The patient came to the emergency department with dyspneu, its happened from 3 months ago and feel more in 2 days ago. Itsn’t have a correlation between temperature and food. Firstly the dyspneu not effected from activity, but now patient already feel dyspneu when he do some daily activity. Patient also have a cough. A cough with a mucous secret and sometimes with blood. Now patient feel cann’t do daily activity, he just lay in his bed. He also feel a fever. A chest pain for patient feel sometimes, its also feel in his back. Now he say he feel weight loss in several months.

Past medical history : patient have already hospitalize in RSUZA 3 months ago with bronkiektasis and old TB with destroyed lung. 2 years ago patient have already consumed OAT for 9 months.

Family medical history : No family members of patients who experienced symptoms like the patient. A family history of lung TB is denied.

A history of drugs use : OAT, Levofloxacin 1x500 mg, sohobion, digoxin 3x0,25mg

A history of social habit : patient cannt do daily activity, and just lay in a bed.

Compos mentis

100/70

mmHg100 bpm

26 kali/

menit37,1° C

VITAL SIGN (22 Mei 2015)

Physical Examination

• Skin : brown, jaundice (-), cyanosis (-), edema (-)Head : hair normal distribution, it is difficult revokedFaces : symmetrical, edema (-), deformity (-)Eyes : anemic (+ / +), jaundice (- / -), secretions (- / -),

RCL (+ / -), RCTL (- / -), pupil isokor -/-Ears : normotia impression, secret (- / -)Nose : secret (- / -), hyperemia (-), NCH (-)Mouth : dry mucous (-), cyanosis (-)Neck : suprasternal retraction (-), lymphadenopathy (-),

stiff neck (-), TVJ: R+2 cmH2O.

• Anterior thoracicInspection

Static : SymmetricDynamic : Asymmetric

Palpation : Left SF > right SF, tenderness (+/-), crepitus (- / -)

Percussion : Dim/ hypersonorAuscultation : Vesicular (+ / +), rhonki (+ / +) 2/3 lower left

lung, wheezing (- / +)

• Posterior thoracic• Inspection

• Static : symetris• Dinamic : Asymetris

• Palpation : right SF<left SF , crepitus (-/-)• Percussion : Dim/hypersonor• Auscultation : vesikuler (-/+), rhonki (+/+), wheezing

(-/+)

Heart◦ Inspection : cardiac ictus not visible◦ Palpation : cardiac ictus palpable di ICS IV, right

midcalivularis line.◦ Percussion : cardiac border

Up : ICS III left parasternal line Left : ICS V left parasternal line Right : ICS III right axillaris anterior line

◦ Auskultation: heart sound I > Heart sound II in right hemithoraks, reguler (+), noisy (-), gallop (-), murmur (-).

Abdomen◦ Inspectionsymetric, distension (-), collateral vein (-), scar (+)◦ Palpationorganomegaly (-), tenderness (-), defans muscular (-)◦ Percussiontimpani, shifting dullness (-), undulation (-)◦ Auscultationperistaltic normal

Exremitycyanosis (-), clubbing finger (-), edema (-/-)

Table 2.4 Laboratory: Date 25-05-2015Pemeriksaan Laboratorium Hasil Nilai Normal

Darah Rutin Hb 10,5 gr/dl 12-15 gr/dlHt 34 % 37-47 %Leukosit 6.400 /mm3 4.500-10.500/mm3

Eritrosit 4,4 x 106 /µL 4,2-5,4 jt/ µLTrombosit

224.000 / mm3 150.000-450.000/mm3

Hitung Jenis

Eosinofil 4 0-6Basofil 1 0-2Netrofil batang 0 0-1Netrofil segmen 65 50-70Limfosit 22 20-40Monosit 8 2-8

Elektrolit Natrium (Na) 141 mmol/L 135-145 mmol/LKalium (K) 4,7mmol/L 3,5-4,5 mmol/LKlorida (Cl) 96 mmol/L 90-110 mmol/L

Diabetes

Glukosa Darah Sewaktu mg/dl <200 mg/dl

Ginjal-Hipertensi Ureum mg/dl 13-43 mg/dlKreatinin mg/dl 0,51-0,95 mg/dl

Table 2.4 Laboratory: Date 05-06-2015

Pemeriksaan Laboratorium Hasil Nilai Normal

Darah Rutin

Hb 11,1 gr/dl 12-15 gr/dl

Ht 35 % 37-47 %

Leukosit 16.800 /mm3 4.500-10.500/mm3

Eritrosit 4,7 x 106 /µL 4,2-5,4 jt/ µL

Trombosit287.000 / mm3 150.000-450.000/mm3

Hitung Jenis

Eosinofil 2 0-6

Basofil 0 0-2

Netrofil batang 0 0-1

Netrofil segmen 76 50-70

Limfosit 11 20-40

Monosit 11 2-8

Elektrolit

Natrium (Na) 142 mmol/L 135-145 mmol/L

Kalium (K) 3,0 mmol/L 3,5-4,5 mmol/L

Klorida (Cl) 95 mmol/L 90-110 mmol/L

Kalsium (Ca) mg/dl 8,6-10,3 mg/dl

Ginjal-Hipertensi

Ureum mg/dl 13-43 mg/dl

Kreatinin mg/dl 0,51-0,95 mg/dl

Examination Electrocardiogram (EKG)04/06/2015

Onterpretation:• Rhythm : Sinus, regular• Rate : 300/3 = 100 x / min• axis : RAD• P wave : 0.08 s 0.1 mV• PR interval : 0.16 s• QRS : 0.08 s• pathological Q: (-)• T inverted : II, III, AVF, V1• ST elevation : (-)• ST depression: (-)• RSR ‘ : -• Conclusion: Sinus, regular, HR 100 x / min, RAD,

ischemic inferior, RVH

Conclusion:Old fracture clavicula dextra, destroyed lung dengan bekas TB.

Plain Photo examination thoraks

Working diagnosis• Bronkiektasis dengan destroyed lung• Cor pulmonal kronik• Pneumonia

TherapyTherapy of cardio:• Bed Rest• IVFD NaCl 15 gtt/i• O2 2-4 l/i• Inj Lasix 1 amp/12 jam• Digoxin 1x0,25 mg• Sildenafil 2x12,5 mg

Therapy of IPD:• Bedrest• IVFD Futrolit 10 gtt/i• Asam traneksamat 3x500mg• Nebule ventolin / 8 jam• Fosfomycin 1gr/12 jam• Sucralfat syr 3xCI

Planning

1. ECHO2. Follow up EKG3. Cek AGDA

Prognosis

Quo ad vitam : dubia ad malamQuo ad fungsionam : dubia ad malamQuo ad sanactionam : dubia ad malam

• Impaired gas exchange related to expiratory airflow obstruction as evidenced by decreased oxygen saturation levels and also make patient dyspneu• Activity intolerance related to

decreased cardiac activity and laboured respirations as evidenced by difficulty in performing activities of daily living

• Decreased cardiac output related to restricted cardiac muscle contractility as evidenced by echocardiographic finding• Impaired tissue perfusion, and airflow

change in lung, related to decreased cardiac contractility and expiratory airflow obstruction also can be effected capillary refilling time >3 seconds

• Fatigue related to decreased cardiac activity and laboured respirations as evidenced by difficulty in performing activities of daily living• Patient may also with anxiety related

to breathlessness as evidenced by patient`s verbalization and facial expressions

• Imbalanced nutrition :less than body requirement related to breathlessness as evidenced by weight loss•Disturbed sleep pattern related to

shortness of breath as evidenced by presence of dark circles around the eyes

Definition

• It is the hypertrophy of the right ventricle resulting from diseases affecting the function and/or structure of the lung, except when these pulmonary alterations are the result of diseases that primarily affect the left side of the heart or congenital heart

World heart association

Etiology• Conditions that restrict or compromise ventilatory function,

leading to hypoxemia or acidosis e.g. deformities of the thoracic cage, massive obesity

• Conditions that reduce the pulmonary vascular bed e.g. primary idiopathic pulmonary arterial hypertension, pulmonary embolus

• Disorders involving nervous system, respiratory muscles, chest wall , and pulmonary arterial tree may also be responsible for cor pulmonale

PATHOGENESIS

GENETIC CAUSES UNKNOWN CAUSES

PATHOGENESIS CONTINUED……

PULMONARY ENDOTHELIAL INJURY

PATHOGENESIS CONTINUED……

VASOCONSTRICTION

REMODELLING

PATHOGENESIS CONTINUED……

SUSTAINED PULMONARY HYPERTENSION

RIGHT VENTRICULAR HYPERTROPHY

PATHOGENESIS CONTINUED……

COR PULMONALE

CLINICAL MANIFESTATIONS

• Dyspnea• Chronic productive cough• Wheezing respirations• Retrosternal or

substernal pain• Fatigue• Polycythemia

• Peripheral edema• Weight gain• Distended neck veins• Full bounding pulse• Enlarged liver • Palpitation• Atypical chest pain• Swelling of the lower extremities• Dizziness and even syncope

DIAGNOSIS• HISTORY COLLECTION

DIAGNOSIS• PHYSICAL EXAMINATION

DIAGNOSIS• LABORATORY TESTS

DIAGNOSIS

• CHEST RADIOGRAPHY

DIAGNOSIS• ELECTROCARDIOGRAPHY• ECHOCARDIOGRAPHY

DIAGNOSIS• CARDIAC CATHETERIZATION

DIAGNOSIS• LUNG BIOPSY

MEDICAL MANAGEMENT• OXYGEN THERAPY

MEDICAL MANAGEMENT• PHARMACOTHERAPY• DIURETIC AGENTS• VASODIALATORS• BETA SELECTIVE AGONISTS• CARDIAC GLYCOSIDES• THEOPHYLLINE• WARFARIN

Thank you