Panel 1st Module : Dyspnoea

1st ScenarioPresented By

1A Group

Thanks to our Tutor : dr. Sri Vitayani, Sp. KK

Medical Faculty Universitas Muslim Indonesia

2010

1A Group

• Maria Ulfah (1102090049)• Irfan Thamrin (1102090056)• Rizki Rahmadhan (1102090063)• Akhmad Edwin Indra Pratama (1102090064)• Fakhrurrazi (1102090065)• Muh. Fadly Aditya (1102090070)• Muhammad Assadul Malik (1102090072)• Inna Mthmainnah Musa (1102090084)• Andi Firman Mubarak (1102090088)• Ainun Martoni (1102090093)• Andi Fajar Apriani (1102090106)• Dzul Ikram (1102090108)• Zarah Alifani Dzulhijjah (1102090115)• Sigit Dwi Pramono (1102090133)• Andi Anugrah Suci (1102090142)• Nur Sabriany Lihawa (1102100156)

1st Scenario

A 60 years old woman complain of feeling easily get tired and heard to breath when she is doing an activity. She can not do chores longer without taking a rest because of hard breathing. Her legs swelling during the day, and lessen at night. Frequent breath and crepitating sound in auscultations exam, are found from physical examinations. Artery pulse and blood pressure are normal, but there is jugular vein obstruction when the patient in a standing position. Ictus cordis is in anterior left of axillary line/intercostals V space. Her chest x-ray shows CTR 0,69 and the lung vascular obstruction is indicated. The patient has been treated with digoxin and diuretic to alleviate her symptoms.

Difficult Words

• CTR: examination to identify cardiomegaly, CTR (Cradiothoracic Ratio) normal range = ≤ 0,5.

• Crepitating sounds : sounds like friction or break from two slices or two parts (fluid and tissue).

• Digoxin : may improve patient well being and reduce hospital admission for worsening heart failure, but has no effect on survival.

• Diuretic: diuretics are recommended in patients with heart failure and clinical signs or symptoms of congestion.

Keywords

• 60 years old women• Tired and difficult to breathe• Complain of rapid fatigue• She has congestion on neck vein• Swelling of the ankle• Crepitation sound on auscultation

examination• Artery pulse and blood pressure in

normal range• CTR 0,69• In rontgen examination there are

congestion of pulmonal vessel dam• Ictus cordis palpable in

axillary/intercostals V space• History of digoxin and diuretic

QUESTIONS AND

ANSWERS

1. Explain about all basic sciences of cardiovascular system!

• Anatomy• Physiology• Histology

AnatomyLeft : linea

medioclavicularis

sinistraRight : linea

parasternalis dextra

Top : intercostal IIBottom : intercostal V

References: SOBOTTA human anatomy Atlas , Understanding of anatomy and physiology Meder

• Aorta

• Vena cava superior

• Vena cava inferior

• Pulmonary Trunk

• Right Auricula

• Right Atrium

• Right Ventriculus• Left Ventricle

• Left Auricula

• Apex

Circumflex arteryLeft coronary artery

Anterior interventricular arteryRight coronary artery

Marginal branch

Great cardiac vein

small cardiac vein

Physiology

HEART CYCLE

References: GUYTON Medical Physiology, Sherwood physiology, Color atlas of physiology

CONDUCTING SYSTEM

Histology

Circulatory System • Heart

Tunica:a. Endocardiumb. Myocardiumc. Epicardium (visceral pericardium)

•  Blood Veesels:-Arteries : Elastic (large) arteries (aorta, pulmonary arteries)Muscular (medium, distributing)Small arteries and arteriolesPre capillariesCapillaries-Veins : Venules and small veinsMedium veinsLarge veins

Reference:Digital Histology An Interactive CD Atlas with Review Text

Large medium small (arteriole)

Small Medium Large

2. What are the phatomechanism of dyspnoea?

pumping capacity of the left heart

the pulmonary capillary pressure,

fluid begins to transude into the lung

tissues and alveoli

fluid begins to transude into the lung

tissues and alveoli

Crepitating sound

oxygen in the blood

peripheral vasodilation

venous return of blood from the peripheral

blood in the lungs

transudation of fluid, more arterial oxygen

desaturation, venous return

Dyspnoea

3. Are there any relation between all the symptoms? Explain it!

• D’ effort dyspnoea: The heart is not able to

increase its pumping capacity to the levels required for the exercise.

Decrease of oxygen.

• Swelling ankle

• Tachypnoea : Metabolic Acidosis

• Crepitating sound : fluid and air in the alveolar (heard when inspirate)

• Vein congestion : increasing the venous return from peripher.

• Palpable ictus cordis: enlargement of left ventricle

• Pulmonary vascular congestion : swelling in the interstisial space of the lungs

4.How to established the dyspnoea in cardiovascular system and the other system?

Cardiovascular Respioratory Gastrointestinale

Accompanied by swelling on the legs

No swelling on the legs Accompanied by pain in the pit of the stomach

Typical breath sound (crapitation sound)

Wheezing sound No sound

High blood pressure Normal blood pressure Feeling full

Irregular e heartbeat. Fast, chest pain in the left side

Faster but regulare Heart burn

5. What are the effects (main effect and side effect) of digoxin and diuretic?

Main Effects of Diuretic: To decrease edema

especially in lung To repair oxygenation and

repair the function of myocardium

Adversed effect of Diuretic: Hypokalemia Dehidration Neurohormonal activation

The main effect : to increase the strength of heart contraction For congestive heart failure, atrial fibrilation

The side effects :*Anorexia, nausea, vomit, and

headache*Toxic symptoms for the heart*Neurologic symptoms*Eye disorders

7. What is the differential diagnosis?

• Congestive Heart Failure • Mitral Regurgitation• Mitral Stenosis• Aortic Stenosis• Coronary Heart Disease

Disease

60 age woman

Fatigue

Dypsnoea

Swelling ankle

Tachypneu

Crapitating Sound

Vein congestion

Palpable ictus cordis

CTR>0,5

Xraycongestion of pulmonal vessel

CHF + + + + + + + + + +

MR + +

MS + + +

AS M>F + + - + + - + + +

CHD F>M + + - + - (S3 n S4)

Thank you

so much !