present CHF.ppt

8/14/2019 present CHF.ppt

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CASE REPORT

CHF

Presented by:Nisa Uswatun Karimah

Lydia Octasari

Advisor:

dr. Erwin Sukandi, Sp.PD


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IDENTIFICATION

Name : Mrs. Rn

Age : 27 years

Sex : female

Address : Ds. Rejodadi Kab. Banyuasin

Marital status: married

Occupation : house wife Religion : moslem

Admitted to hospital : November 5, 2008


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ANAMNESIS


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CHIEF COMPLAIN

Shortness of breath again so heavy since

1 week before admission


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HISTORY OF ILLNESS

3 months before admission:

shortness of breath, depended on positionand activity. She felt shortness of breath

when go to toilet. She felt better if she sat orslept with taking 2-3 pillows. Shortness ofbreath wasnt depended on weather &emotion, not followed by mengi voice. Wakeup midnight caused shortness of breath (+),heart palpitation (+). Chest pain (-), cough(-), fever (-), sweating at night (-).


6/47

Swelling in both of lower extremity (+),

swelling in upper eye lids (-). Being

yellowish in eyes and skin (-). Epigastrium

pain (+), nausea (+) but no vomit. No

problem in urination and defecation. She

went to RSMH and was hospitalized for 10

days until she got well.


7/47

1 month before admission

She complained of having shortness of breathagain, depend on position & activity. She felt

shortness of breath after walking 5 m, being

better if she took a rest. It wasntdepended onweather or emotion, not followed by mengi

voice. Slept with 3-4 pillows. Wake up in

midnight caused by shortness of breath (+).

Heart palpitation (+). Chest pain (-), cough (-),

fever (-), sweating at night (-). Swelling in both

two lower extremity (+).


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Swelling in upper eye lids (-). Being

yellowish in eyes and skin (-). Being

yellowish in eyes and skin (-). Epigastrium

pain (+), nausea (+) but no vomit. No

problem in urination and defecation. She

was taken to RS Siti Khodijah andhospitalized for 25 days until she got well.


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1 week before admission

She complained of having shortness ofbreath again so heavy, depended on position

& activity. She felt better if she sat, but she

couldntwalk anymore. It wasntdepended onweather & emotion. Not followed by mengi

voice. Slept with taking 4-5 pillows. Woke up

in midnight caused by shortness of breath (+).Heart palpitation (+). Chest pain (-), fever (-),

sweating at night (-).


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Swelling in both of lower extremity (-),

swelling in upper eye lids (-). Being yellowish

in eyes and skin (-). Epigastrium pain (+),

nausea (+) but no vomit. No problem in

urination and defecation. She was taken to

RSMH again for these complains.


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HISTORIES OF PAST ILLNESS

H/ of heart disease since 14 years ago,

hospitalized min. once in a year

H/ of joint and bone pain (+) since 10 years old

H/ of hypertension was denied

H/ of DM was denied

H/ of kidney disease was denied

H/ asthma was denied

H/ being blue when baby was denied

H/ gastric pain since 10 years ago


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HISTORIES OF FAMILY DISEASE

H/ of heart disease (+) in her mother

H/ of hypertension (+) in her mother, too


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PHYSICAL EXAMINATION


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GENERAL EXAMINATION

General condition : sick

Sickness condition : severe sickness

Consciousness : compos mentis

Blood pressure : 90/60 mmHg Pulse rate : 100 x/min, irregular

Respiration rate : 40 x/min

Temp. : 36,90

C Dehydration : (-)

Nutrition : weight = 35 kg, height = 155 cm

impression : undernutrition


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SPESIFIC EXAMINATION

SkinSkin color is puce, normal pigmentation,efloresence (-), icteric (-), cyanotic palm &

palmar (-), scar (-), hyperhydrosis (-),normal hair growth, good turgor, wet/dryin palpitation (-), subcutaneous nodule (-).

Lymph gland

no enlargement of the lymph nodes onsubmandibular, neck, axillaries, &inguinal.


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Head

oval, symmetrical, puffy face (-), deformity

(-), malar rash (-), alopecia (-)

Eyes

exophtalmus & endophtalmus (-),

edematous superior palpebra (-), pale of

conjunctiva palpebra (-), icteric sclera (-)

Nose

epistaxis (-), normal nasal septum and

mucous layer


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Ears

good hearing, normal both of meatus

acusticus externus

Mouth

rhagaden of lips (-), stomatitis (-), papil

atrophy (-), gum bleeding (-), fetor oris (-)

Neck

thyroid gland not palpabled, thyroid bruit (-),

JVP (5+2) cmH2O, hypertrophy of musculus

sternocleidomastoideus (-), stiffness (-)


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Thorax

normal shape, extended intercostal section

(-), retraction (-), venectasis (-), spider naevi(-)

Lung

I : symmetrical of static & dynamic right = leftP: right stemfremitus is weaker on base of

lung

P: dull in right lung started at ICS IV, sonoron the left lung

A: ves (+) weaker on base of right lung, softwet rales on all lung, wheezing (-)


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Cor

I: ictus cordis was seen in ICS VI

P: ictus cordis was palpable in ICS VI, thrill

(+)

P: upper boundary of cor is at ICS III, left

boundary is at LAA sinistra, right boundarycant be evaluated

A: HR = 110 x/min, irregular, murmur (+)

systolic & diastolic on all the valves, gradeIV, punctum maximum is at mitral valve,

gallop (-)


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Abdomen

I: flat, venectation (-)

P: pain on epigastrium region, spleen is

unpalpable, liver is palpable 7 fingers

under arcus costa, sharp edge, elastic

consistency, flat surface, palpable pain (+)P: tympany, shifting dullness (-)

A: bowel sound (+) normal

External genitalia

not examined


21/47

Upper extremity

pain on join (+), pale on finger (-), erythema

of palm (-), pitting edema (-), clubbing finger

(-), tremor (-), normal physiological reflex

Lower extremity

pain on join (+), pale on finger (-),

erythema of palm (-), pitting edema (-),

clubbing finger (-), tremor (-), normal

physiological reflex


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ADDITIONAL EXAMINATION


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ELECTROCARDIOGRAPHY (Nov 5, 2008)

AF, normal axis, HR = 110-140 x/min, P

wave cant be evaluated, QRS complex

0.04 seconds, R/S V1 < 1, S V1 + R

V1/V5/V6 > 35, S persistent (+) in V5-V6

Impression:

rapid ventricular respond AF + LVH


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LABORATORY FINDINGS (Nov 5, 2008)

Blood analysis

Hemoglobin : 10.8 g/dl (14-18 g/dl)

Hematocrite : 32% (40-48%)

Leucocyte : 6500/mm3 (5000-10000/mm3)

ESR : 30 mm/hr (< 10 mm/hr)

Thrombocyte : 291,000/mm3(200,000-500,000//mm3)

Diff count : 0/5/2/77/12/4


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BSS : 105 mg/dl

Cholesterol total : 155 mg/dl (< 200)

HDL-cholesterol : 45 mg/dl (> 55)

LDL-cholesterol : 91 mg/dl (< 130)

Triglyceride : 96 mg/dl (< 150)

Uric acid : 4.5 mg/dl (1.6-6.0)

Ureum : 18 mg/dl (15-39)

Creatinin : 0.7 mg/dl (0.9-1.3)

Total protein : 6.6 g/dl (6-7.8)

Albumin : 3.1 g/dl (3.5-5)

Globulin : 3.5 g/dl


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Total bilirubin : 1.8 mg/dl (0.1-1)

Direct bilirubin : 1.22 mg/dl (< 0.25)

Indirect bilirubin : 0.58 mg/dl (< 0.75)

SGOT : 35 U/l (< 40)

SGPT : 39 U/l (< 41) LDH : 266 U/l (160-320)

Sodium : 135 mmol/l (135-155)

Potassium : 5.0 mmol/l (3.5-5.5)


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Urinalysis

Epithelial cell : (+)

Leucocyte : 0-1/LPB (0-5/LPB)

Erythrocyte : 0-3/LPB (0-1/LPB)

Cylinder : (-) (negative)

Crystal : (-) (negative)


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CHEST X-RAY (Nov 5, 2008)

Condition of the photo was good

Right and left are equal Trachea was in the middle

No extended intercostal section

Condition of the bone was good, no fracture CTR was difficult to seen

Right costophrenicus angle was difficult to

evaluated, left costophrenicus was keen

Right diaphragm is at ICS II

Parenchyme cephalization (+)

Impression: subdiaphragm process + cardiomegaly

+ acute lung edema


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ECHOCARDIOGRAPHY

EDO : 5.47

ESO : 4.06

PW : 0.65

IVS : 0.74 LA : 13.3

AO : 3.04

EF : 50.3

FS : 25.8 LA/AO : 4.37

LV dilatation, LA dilatation

LVH (-)

LV EF 50%

MS severe, MVA = 1.76,MPG 13-19

MR severe

AR moderate

AS mild-moderate TR moderate

~ MVD e.c. RHD


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RESUME

A woman initialed Mrs. Rn, 27 years,admitted to hospital in November 5, 2008 withshortness of breath again so heavy since 1 weekbefore admission as the chief complain.

3 months before admission, she complainedof having shortness of breath, depended onposition & activity after going to toilet. She feltbetter if she took a rest and slept with 2-3 pillows.

Wake up in midnight caused by shortness ofbreath (+), heart palpitation (+). Swelling in bothof lower extremity (+), epigastric pain (+), nausea(+). She went to RSMH & hospitalized.


38/47

1 month before admission, she

complained having shortness of breath again,

depended on position & activity after walking 5m. She felt better if she took a rest or slept

with 3-4 pillows. It was not depended on

weather & emotion, not followed by mengivoice. Wake up in midnight caused by

shortness of breath (+), heart palpitation (+).

Swelling in both of lower extremity (+),

epigastric pain (+), nausea (+). She went toRS Siti Khodijah and hospitalized for 25 days.


39/47

1 week before admission, she complainedhaving shortness of breath again, depended onposition & activity. She felt better if she took arest or slept with 4-5 pillows. She couldnt walkanymore. It was not depended on weather &emotion, not followed by mengi voice. Wake up inmidnight caused by shortness of breath (+), heartpalpitation (+), epigastric pain (+), nausea (+).She went to RSMH again for these complains.

She had history of heart disease since 14

years ago, hospitalized minimal once in a year,and history of pain in joint & bone since 10 yearsold. History of heart disease & hypertension (+) inher mother.


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From physical examination, the generalcondition was severe sickness, consciousnesswas compos mentis. BP was 90/60 mmHg, pulse

rate 100 x/min, irregular, RR = 40x/times, temp36.90C, RBW = 70,7% with undernutritionimpressive, JVP (5+2) cmH2O. In anterior &posterior of the lung, there was soft wet rales on

both of legt and right lung, while in cor, ictuscordis was seen and palpable in ICS VI, thrill (+),upper boundary is at ICS III, left boundary is atLAA sinistra, & right boundary cantbe evaluated,HR = 110 x/min, irregular, murmur (+) systolic &

diastolic on all the mitral valves, gallop (-). Whileabdomen examination, liver is palpable 7 fingersunder arcus costa.


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FRAMINGHAM SCORE

Major criteria : Paroxysmal nocturnal dyspnea (+)

Distention of neck vein (-)

Rales on pulmo (+) Cardiomegaly (+)

Acute pulmonary edema (+)

Gallop S3 (-) Increased of JVP (+)

Hepatojugular reflux (+)


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Minor criteria :

Extremity edema (-)

Cough in night time (-)

Dispnea deffort (+)

Hepatomegaly (+) Pleural effusion (-)

Decreased of vital capacity (-)

Tachycardia (> 120 x/min) (-)


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WORKING DIAGNOSIS

CHF e.c. MVD e.c. RHD

DIFFERENTIAL DIAGNOSIS

CHF e.c. MI/MS e.c. RHD

CHF e.c. congenital valve abnormality


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TREATMENTS

Nonpharmacology :

O23 l/min

Bedrest (half-sit

position) Cor diet III

Pharmacology :

IVFD D5 gtt X/min(microdrip)

Furosemide amp 1x1 Spironolactone tab

1x25 mg

Digoxin 1x0.25 mg

Laxadin syr 3x1 c Omeprazole tab 1x20

mg


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PLANNING

Repeat echocardiography

Electrolyte examination


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PROGNOSIS

Quo ad vitam : dubia et malam

Quo ad functionam : dubia et malam


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TERIMA KASIH

present CHF.ppt

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