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Patient Identity
Name
Gender
Age
Medical Record
Date of Admission
Address
: Mr. S
: Male
: 60 years old
: 362481
: 11 January 2015
: Jln. Flamboyan, MKS
Anamnesis
Chief Complaint: Shortness of breath
Shortness of breath has been experienced since
Anamnesis
The pain exacerbates with exercise and lessen
with rest. Dyspnea on effort (+), Orthopnea (-),
Paroxysmal Nocturnal Dyspnea (+), Cough (+)
intermittent since 1 year ago. Palpitation (+),
Fever (-) Nausea (-) Vomit (-). Defecation and
urination: normal.
Risk Factors
Physical Examination
General Status:
Moderate illness/ Well nourished/ Conscious
Nutritional Status: Normal (BMI: kg/m)
Weight : 55 kg
BMI: 20.2 kg/m2
Height : 165 cm
Vital Signs:
Blood Pressure : 130/60 mmHg
Pulse Rate
: 80 bpm
Respiratory Rate
: 25 bpm
Temperature
: 36.7 0C
Physical Examination
Head and Neck Examinations:
Eye
Lip
Chest Examination
Inspection : Symmetric left=right
Palpation : No mass, no tenderness, vocal fremitus left=right
Percussion : Sonor left = right, lung-liver border in ICS VI right
anterior
Auscultation: Breath sound
: vesicular
Additional sound : Ronchi
Wheezing -/-
+ +
Physical Examination
Cardiac Examination
Inspection : Ictus cordis was not visible
Palpation
: Ictus cordis was not palpable
Percussion :Right heart border in right parasternal
line, left heart border two fingers from left
midclavicular line ICS VI.
Auscultation :
Heart sound : S I/II regular, no gallop, no
additional sound
Physical Examination
Abdominal Examination
Inspection
: flat, following breath movement
Auscultation
: Peristaltic sound (+), normal
Palpation
: No mass, no tenderness, no
palpable liver and spleen
Percussion
: Tympani (+), ascites (-)
Extremities Examination
Pretibial edema -/ Dorsum pedis edema -/-
Electrocardiography(ECG)
Interpretation of ECG
Echocardiography
Conclution of
Echocardiography
Systolic and diastolic dysfunction of the left ventricle
Chest X-rays
Conclusion :
Normal Pulmonary
Cardiomegaly with
dilatation aortae
Laboratory Finding
Complete Blood Count
Test
Result
Normal value
WBC
11.1/ul
RBC
5.61/l
HGB
16.7 gr/dl
14 18
HCT
49.1%
40 54
PLT
290 000/l
Electrolyte
Test
Result
Normal value
Na
146 mmol/l
136-145
4.5 mmol/l
3.5-5.1
Cl
113 mmol/l
97-111
Laboratory Finding
Blood Chemistry
Test
Result
Normal value
GDS
98 mg/dl
<140
Ureum
22 mg/dl
10 50
Creatinine
1.5 mgr/dl
< 1.3
SGOT
28 u/l
<38
SGPT
34 u/l
<41
Test
Result
Normal value
CK
77.7 U/L
<167
CK-MB
15.4 U/L
<25
Troponin-T
<0.02
<0.05
Cardiac Enzymes
Diagnosis
CHF NYHA IV e.c CAD (OMI
Anteroseptal)
Atrial Fibrillation Normal Ventricular
Response (AF NVR)
Management
O2 2-4 lpm via nasal canul
IVFD NaCl 0.9% 10 dpm
Fluid Balance
Inj. Furosemide 40 mg/12 hours/ IV
Fasorbid 10 mg 1-1-1
Aspilet 80 mg 0-1-0
Captopril 6,25 mg 1-1-1
Simvastatin 1 x 20mg
Digoxin 0.125 mg 1-0-0
Planning
ECG control
DISCUSSION
Congestive Heart
Failure (CHF)
DEFINITION
Etiology of
Heart Failure
Main Causes
Ischemic heart disease
(35%-40%)
Cardiomyopathy(dilated)
(30-40%)
Hypertension ( 15-20%)
Other Causes
Arrhythmias
Valvular heart disease
Congenital heart disease
Pericardial disease
Hyperdynamic circulation
Alcohol and
drugs(chemotherapy)
Major Criteria
Minor Criteria
Extremity edema
Cardiomegaly
Nocturnal cough
Gallop S3
Hepatojugular reflux
Increased of JVP
Hepatomegaly
Rales or ronchi
Pleural effusion
Tachycardia ( 120bpm)
Dyspnea deffort
Classification of CHF
Pathophysiology of CHF
Treatment of CHF
Causes CAD
Coronary
RISK FACTORS
INVESTIGATION
Electrocardiogram (ECG)
Treadmill Test
Echocardiography
Coronary Angiography
Multi-Slice Computed Tomography Scan (MSCT)
Cardiac Magnetic Resonance Imaging (Cardiac
MRI)
Radionuclear Medicine
TREATMENT
Lifestyle Changes
Eat a healthy diet
Quit smoking, if you
smoke
Exercise
Lose weight, if you are
overweight or obese
Reduce stress
Medicines
Cholesterol-lowering
medicines
Anticoagulants
Aspirin
ACE inhibitors
Beta blockers
Calcium channel
blockers
Nitroglycerin
Long-acting nitrates
TREATMENT
Special Procedures
Angioplasty (PTCA)
Coronary artery bypass surgery
Enhanced External Counterpulsation (EECP)
Cardiac Rehabilitation
Exercise training
Education, counseling, and training
THANKYOU