Case Coba - Copy

7/29/2019 Case Coba - Copy

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A 65 y/o man with Congestive

Heart FailureAngelia Elisabeth Mambu030.09.019

MEDICAL FACULTY OF TRISAKTI UNIVERSITY

RSUD KARAWANG


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Identity Mr. NurhadiName

62 y/oAge

MaleSex Jl.Citarum no 29 Tunggakjati, Karawang

BaratAddress

-Ocupation

MoeslimReligion

MarriedMarital Status

High SchoolEducation

SundaneseEthnic

14th

June 2013Admitted


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Shortness of breath since 2

days before hopitalizedChief

Complain

Fatigue

Swelling in both feet Cough Lack of sleep

AdditionalComplain


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History of Present IllnessThe patient came to Emergency Unit of Karawang

Hospital with complaint of shortness of breath since 3

months before hospitalized. The symptom felt worseningand appeared when he is in rush and during her normalactivities such as sweeping . To relief the symptom he isusing 2 - 3 pillows when sleeping. She always suddenlywoken up when she is sleeping because of breathlessness.

He also complains about his swelling feet whichgetting worse from day to day. She denied having a chest

pain, fever, nausea and vomit but suffered a bit of coughand exhausted.


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History of Past illness

Hypertension(+) DiabetesMelitus (+)

Asthma (-)


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History of Family Illness

History of FamilyIllness

Same disease (-) Hypertension (+) Diabetes Melitus

(+) Asthma (-)

Personal and SosialHistory

Smoking (-)

Alcohol (-)

Exercise regularly (-)

ConsumeHypertension drugsand DM drugsregularly


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Physical Examination


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General Condition

General

appearance Moderately ill

Consciousness

Compos mentis

Blood

Preasure150/90

Heart Rate

96 x/min

RespirationRate

24 x/min

Temperature36oC

VitalSign


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Normochepaly, black hair,good distributionHead

Anemic conjungtiva -/- Icteric sclera -/-Eyes Thyroid gland & lymph nodes

enlargement are not palpable JVP : (5+4) cmH2O

Neck


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Thorax - HeartInspection

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


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Thorax - Lung

SymmetricalInspection

Equal vocal resonancePalpation

Sonor in both lungsPercussion

Vesicular, Ronchi (+/+) at baseboth lungs, Wheezing (-/-)Auscultation


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Abdomen brown skin, symetrical

Inspection

Bowel sound (+)

Auscultation

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

Tympanic, no pain present on abdominalpecussion, Shifting dullness (-)Percussion


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Ekstremity

+ +

+ +

Warm Acrals Edema

- -

+ +


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Laboratory test (14th June 2013)Result Normal

Hb 12,3 12 17 g%

Leukosit 7.990 5000

10000Trombosit 193.000 150rb 450rb

Hematocrit 35 37 48 %

GDS 45 80 140 mg/dl

Ureum 48,6 10 45 mg/dl

Creatinin 1,52 0,4 1,5 mg/dl

Na 136 134 145 mmol/L

K 4,6 3,5 5,6 mmol/L

Cl 106 100 110 mmol/L

CK-MB 22 < 24 U/l


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Laboratory test

16th June2013

GDS = 248

18th June2013

GDS = 190


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ECG old MCI anterior


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Thorax foto AP

CTR > 50%

Enlargement of Left Ventricle(LVH)

Enlargement of Left Atrium(LAH)

Right costophrenicus angle isblunt

Pleura efusion dextra


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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 : hipokinetikringan inferior wall

Katup: Ao 3 cupis, kalsifikasi (+), AR

trivial, MR mild, TR mild, PR mild

Doppler : E/A > 1, Ao V max 1,1m/s. mPaP 20 mmHg

KESIMPULAN

CAD, LA dilated

Fungsi sistolik LV baik, EF55%

LVH (+) konsentrik

AR trivial, MR mild, TR mild,PR mild


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Working Diagnosis

CHF NYHA II et causa CADand

Hipoglycemia in Diabetes Melitus tipe II


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Diferential Diagnosis

CHF NYHA II e.c HHD

CHF NYHA II e.c Cardiomiopathy


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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


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Prognosis

Ad vitam

AdSanationam

AdFungsionam

Dubia ad

bonam Dubia ad

malam

Dubia admalam


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CHF

Congestive heart failure (CHF) is a condition inwhich the heart's function as a pump is

inadequate to deliver oxygen rich blood to thebody.


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Etiology

The most common causes of congestive heartfailure 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


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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


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Diagnosed

Mayor

Paroxysmal nocturnal dyspnea Neck vein distention Rales Radiographic cardiomegaly Acute pulmonary edema

S3 gallop Increased Jugularis Vena

Pressure Hepatojugular reflux

Minor

Bilateral ankle edema Nocturnal cough Dyspnea on ordinary exertion Hepatomegaly Pleural effusion

Decrease in vital capacity byone third from maximumrecorded

Tachycardia (heart rate>120beats/min.)

Framingham Criteria for Congestive HeartFailure

.


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Framingham Criteria for CongestiveHeart Failure

2 major1 major2 minor

Diagnosis of CHF requires the simultaneouspresence of at least


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NYHA Classification - The Stages of

Heart FailureNo limitation of physical activity. Ordinary physical activity

does not cause undue fatigue, palpitation, or dyspnea(shortness of breath).Class I

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

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

Class IIIUnable to carry out any physical activity without

discomfort. Symptoms of cardiac insufficiency at rest. Ifany physical activity is undertaken, discomfort isincreased.

Class IV


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Treatment

Diet Exercise

NonFarmachologist

Ace inhibitor Beta blocker Diuretic

Digoxyn

Farmachologist

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