An 84-year-old woman with known heart failure

presented with dyspnea for 4 weeks during which time she

developed dyspnea and fatigue on minimal exertion and
even at rest. She also complained of orthopnea and
reported that most of the past week she slept sitting in a
recliner. Prior to sleeping on a recliner, she had had one
episode of paroxysmal noctuurnal dyspnea. Her past
medical history was remarkable for hypertension. She
denied chest pain, palpitation or dizziness. She also
reported right upper quadrant pain associated with nausea
and loss of appetite but no vomiting. She had chronic leg
swelling which has gotten so severe over the past several
weeks that she could not wear her shoes. She responded
to her worsening symptoms by retricting her activities and
did not see her physician. At the emergency department,
her jugular venous pressure was elevated at 15 cm of
water. She had positive hepatojugular reflux, a right-sided
third heart sound and an enlarged soft tender liver. She had
no pulmonary rales of wheezing. She had severe bilateral
pitting edema in both of her legs up to mid-thight areas with
multiple blisters over lower legs. She also had evidence of
venous insufficiency with brown pigmentation and
induration of skin. A loud second heart sound at left fourth
intercostal space suggested that her estimated pulmonary
artery systolic pressure was elevated at 40-45 mm Hg. She
had normal sinus rhythm by an electrocardiogram. Her
chest radiograph was remarkable for marke cardiomegaly
and pulmonary venous congestion. Her prior left ventricular
ejection fraction was unknown and subsequent
echocardiogram revealed a left ventriculer ejection fraction
>55%.
 Seorang wanita 84 tahun diketahui gagal jantung
datang dengan sesak nafas selama 4 minggu di rasakan
sesak nafas dan kelelahan pada aktifitas yang minimal
bahkan pada saat istrahat. Dia juga mengeluhkan
orthopnea dan melaporkan bahwa pada minggu-minggu
terakhir ia lebih banyak tidur dengan posisi duduk di kursi.
Sebelum tidur di kursi, dia telah memiliki satu episode
paroxysmal noctuurnal dyspnea. Riwayat penyakit
terakhirnya yaitu hipertensi yang parah. Dia menyangkal
adanya nyeri dada, palpitasi atau pusing. Dia juga
mengeluhkan nyeri di kuadran kanan atas yang berkaitan
dengan kelelahan dan nausea tetapi tidak muntah. Dia
mempunyai pembengkakan kaki yang kronik yang sudah
begitu parah selama beberapa minggu terakhir dia tidak
bisa menggunakan sepatu. Dia merespon gejalanya yang
semakin memburuk dengan membatasi aktifitasnya dan
tidak menemui dokternya. Di UDG, tekanan vena
jugularnya meningkat pada 15 cm of water. Dia memiliki
reflux hepatojugular yang positif, bunyi jantung ketiga
bagian kanan dan hepar membesar dan teraba lunak. Dia
tidak mempunyai bunyi paru wheezing. Dia memiliki pitting
edema bilateral yang parah di kedua kakinya sampai
dibagian pertengahan dengan banyak lecet diatas kakinya.
Dia juga terbukti memiliki insufisiensi vena dengan
pigmentasi coklat dan indurasi kulit. Bunyi jantung kedua
pada ICS 4 mengarah pada perkiraan arteri puulmonari
sistoliknya meningkat 40-50 mmHg. Dia memiliki irama
sinus yang normal oleh EKG. Dari hasil rontgen dadanya
didapatkan tanda kardiomegali dan kongesti vena
pulmonal. Hasil fraksi ventrikular ejeksinya sebelumnya
tidak diketahui dan ekokardiogram berikutnya
mengungkapkan fraksi ejeksi ventrikel kiri >55%.