Case Based Discussion

Complication Congestive Heart Failure

Lecturer Advisor
dr. HM. Saugi Abduh, SpPD,KKV,FINASIM

Presented by
Aprilia Nugraheni
012116332

PATIENT IDENTITY

Name
: Mr. R
Sex
: Male
Age
: 62th Years Old
Religion
: Moslem
Job
: famers
Adress
: Cabean RT 05/RW 6 , Demak
MR number : 01.28.09.74
Room
: B. Izzah II. L4
Check in date : 19 March 2016
Check out date : 30 March 2016

ANAMNESIS

Chief complaint : Dyspneu and chest pain

Patient came to the Islamic hospital Sultan Agung with chief
complains dyspneu and chest pain since 17 month ago. dyspneu
become aggravate and patient felt difficult to breath, dyspneu during
sleep. Chest pain located on the left side. The patient felt abdominal
fullness, swollen limbs, abdominal bloating, constipation . The patient
has abdominal fullnes 3 month ago.The patient also complaint
weakness and being lethargic, and fever. Petient is heavy smoker
cigarette since he was young and coffee. He has diagnostic cardiac
disease 17 month ago. His mother have lung disease.

Past History
DM history (-)
Hypertension (-)
Hyperlipidemia (-)
Heart disease (+): 17 month ago
Smooking cigarette (+)
Overweight (+)
Family History
DM history (-)
Hypertension (-)
Heart disease (-)
Overweight (-)
Hyperlipidemia (-)
Personal and social history
Patient is a famer, hospital cost by JKN
He has 3 children and all of them has been marriage
Economic status : middle-low

Review of systems ( Head-to-toe evaluation)

Skin : brown skin,
Head : headache (+)
Eye : blured vision +/+, red eyes -/-, icteric -/Ears: hearing lost -/-, ring -/-, discharge -/Nose : bleeding -/-, discharge -/Mouth : cyanosis -, thrush -, bleeding gums Throath : pain swallowing -, hoarseness +, difficult in swallowing +, snoringNeck : enlargment of the gland Chest : dyspneu +, pain +, cough +, blood-, sputum (+)
Cardiac : chest pain +, palpitations +
Stomach : abdominal pain +, decreassed appetite+, nausea +, vomiting-,
defecation/miction -/+
Musculosceletal : weakness +, rigid -, pain Extrimity : oedem on upper and lower extrimity (+), Ulcers (-),

Physical Examination
General status

General : Dyspneu, chest pain and oedem (+)

Nutrient Status
: H= 174cm, W= 90 kg
BMI = W(kg)/H (m)
= 90/3,0276
= 29,7284799 (Overweight)

Below 18.5 : underweight

18.5-24.9 : healthy weight
25-29.9 : overweight
30-above : obese

Vital Sign

BP : 120/80 mmHg
HR : 83 bpm; regular ritmic,equality same, pulse alternan(-) pulse deficit (-)
amplitude strong.
BF : 28 times/minute
Temp :38.4 degree of celcius

Head

: chepalgia (+)
Eyes : anemic conjungtive (-)/(-), icteric (-)/(-)
Ears : Hearingloss (-)/(-), discharge (-)/(-)
Nose : Symetric, secret(-), nostril breath (-)
Esophagus : hyperemic (-), pain devour(-)
Mouth : cyanosis (-), dry lips (+)
Neck : trachea deviation (-), lymph hypertropy (-)
Chest: barrel chest (+) ,
* Stomatch : acites (+),
Skin : hyperpigmentation (achantosis nigricans)(+)
Extrimity : Oedem lower and upper extrimity (+), Ulcers (-), pitting udem (+)
INTERPRETATION:

normotension, Dyspneu, fever, and pitting edema,

emfisematus chest

Thorax-pulmonary

inspection
Static

Palpation
Dextra
Dynamic
Sinistra

Anterior
BF: 30t/minute
Diameter AP>LL
Hemithorax size L=R
Hyperpigmentation (-), spidernavi (-),
tumor (-), inflamation (-)
SIC: retraction intercosta

Anterior
Palpation pain (+), tumor (-),
stemfremitusmovement
dextra=sinistra
Hemithorax
L=R retraction
intercosta
Additional mucsle respiration (-)
Palpation pain (+), tumor (-),
stemfremitus dextra=sinistra

Posterior
BF: 30t/minute
Diameter AP>LL
Hemithorax size L=R
Hyperpigmentation (-), spidernavi (-),
tumor (-), inflamation (-)
SIC: retraction intercosta

Posterior
Palpation pain (-), tumor (-), stemfremitus
dextra=sinistra
Hemithorax movement L=R
Additional mucsle respiration (-)
Palpation pain (-), tumor (-), stemfremitus
dextra=sinistra

Percussion

Anterior

Posterior

Dextra

Shifting dullnes (+)

Shifting dullnes (+)

Sinistra

Shifting dullnes (+)

Shifting dullnes (+)

Auscultation

Anterior

Posterior

Dextra

Vesicular (-), ronchi (+),

wheezing (-), pleural rub (+)

Vesicular (-), ronchi (+),

wheezing (-)
pleural rub (+)

Sinistra

Vesicular (-), ronchi (+),

wheezing (-), pleural rub (+)

Vesicular (-), ronchi (+),

wheezing (-)
pleural rub (+)

interpretation : dyspneu, susp oedem pulmonary

Thorax-Cardiac
Inspection

Ictus cordis seen

Palpation

Ictus cordis is palpable on SIC VII linea mid clavicle sinistra, thrill
(-)

Percution

Dull sound
Upper broderline of heart
: SIC II Linea sternalis sinistra
Waist of heart
: SIC II Linea parasternalis sinistra
Lower Right broderline of heart : SIC VI mid claviculla dextra
Lower Left broderline of heart
: SIC V Linea axillaris anterior
sinistra

Auscultation

Aorta Valve
: S I II pure, reguler . A1<A2
Pulmonal Valve : S I II pure, reguler . P1<P2
Trikuspidal Valve : S I II pure, reguler . T1>T2
Mitral Valve
: S I II pure, reguler . M1>M2
sound : (gallop S3)
interpretation Additional
: Susp. Cardiomegali

Abdomen
Inspection
Distention
(-), cicatrice (-), striae (-), caput medusa (-),
Interpretationv
Interpretation
enlargment of vein (-)
Auscultation Peristaltic (+) ; 14 times / minute
Percution

Thympani all abdominal surface,

Liver span : dextra ; 13 cm. Sinistra ; 8cm.
Traubes space : (-)
Shiting dullness : (+)

Palpation

Superficial : Mass (-)

Deeper
: Abdominal pain (regio epigastrium) (+),
hepatomegali (-), spleenomegali (-), Murphy signs (-)

Interpretation : susp. Ascites , hepatomegali, spenomegali

Extrimities
Extrimities

Superior

Inferior

Edema

+/+

+/+

Cold Extrimity

-/-

-/-

Reflex physiologist

+/+

+/+

Icteric

-/-

-/-

Pitting edema

+/+

+/+

Interpretation : oedem extrmity, pitting edema

Follow Up
Date

19-032016

20-032016

21-032016

22-032016

23-032016

24-032016

25-032016

26-032016

27-032016

28-032016

Dyspne
u

Dyspne
u
weakne
ss

Left leg
hurt

Left leg
hurt

Weaknes
s
leg hurt

Weaknes
s

Weakness
defecation
-

Weakness
dyspneu

Weakness
defecatio
n-

Weaknes
s,
vomiting

120/80

90/0

110/70

120/70

80/0

140/100

130/80

120/80

130/80

100/60

83 bpm

- bpm

100bpm

63 bpm

98bpm

104bpm

87bpm

134bpm

98bpm

79bpm

BF

30 t/m

- t/m

22t/m

24 t/m

24t/m

28t/m

20t/m

37t/m

24t/m

22t/m

36,8 dc

37 dc

36.7 dc

36.9dc

37.4dc

38.4dc

39.1dc

39.5dc

37.4dc

36.8dc

GDS

111

95

95

95

172

108

118

104

116

109

BP
HR

LABORATORY EXAMINATION

Hematology and Chemical 19-03-2016

19-03-2016

Result

APPT/PTTK

23,6 second

21.8-28.0

Control

27,9 second

20.9-28.3

PPT

12,8 second

9.3-11.4

Control

11,4 second

8.8-12.0

20/-03/2016 Result

Hemoglobin

15,8

13.7-17.3

Hematokrit

47.6

33-45

Leukosit

14.15

3.8-10.6

Trombosit

357

150-440

Conclusion: hipoalbuminemia
Leukositosis, hyperuricemia,
azotemia

Result

Protein Total

5,34

6.0-8.0

Albumin

2,28

3.4-4.8

Globulin

3.06

3.4-4.8

GDS

111

<200

20/03/2016

Result

Uric Acid

8.4

3.5 -7.2

Ureum

62

10 50

Creatinin darah

1.53

0.6 - 1

Natrium

141.9

135147

Kalium

4.31

3.5-5

Cloride

101.4

95-10.5

Calcium

9.7

8.8-10.8

Magnesium

1.9

1.6-2.4

HBsAg

Non reaktif

Non reaktif

KIMIA BLOOD GAS ANALYSIS

20/3/2016

Result

FIO

75.0

pH

7.35

pH(37C)

7.34

pCO2

35

pCO2(32C)

36

pO2

50

pO2(32C)

53

S02%

84

94-98

HCT

52

39-49

Hb

17.4

13.2-17.3

HCO3

19.3

22-29

TCO2

20.4

23-27

A-aDO2

440.6

O2Ct

20.6

Lactate

Conclusion: asidosis
respiratorik, 3.07

7.37-7.45

33-44

71-104

EKG

INTERPRETATION
1.
2.
3.
4.
5.

Rhytm
: regular sinus
Heart rate : 1500/ 20: 75bpm
Axis
: lead I (-) Avf (+) RAD
Transition zone : tidak ditemukan
Morphology:
P Wave
: amplitudo 0,1mv. Duration
0.08s
2. Interval PR
: 0.20s
3. RR : V1, V2, V3
4. QRScomplex : 0.08s
5. ST Segment
: elevation (-) depression
(+)
6. Interval QT
: 0.12s
7. T Wave
: inverted (+) tall (-)
V2, V3 and V4
1.

Conclusion : RAD, low voltage ,

RBBB, iskemik anteroseptal, RVH,

CHEST X RAY

Interpretation

COR : CTR> 50% movement

apex to laterocaudal, aorta
elongation
PULMO: broncovascular image
normal

Conclusion :
COR: Cardiomegali (LV),
elongation of aorta
PULMO: Efusi Pleura duplex

ECHOCARDIOGRAPHY

ABNORMALITY DATA
Anamnesis

Physical Examination

1. Dyspneu (1)
2. Orthopneu (1)
3. Chest pain left
side(1)
4. Weakness and
being lethargic
(2)
5. Fever (4)
6. Smoking
cigarette
7. Increasing Thrist
(4)
8. Cough(1)

1. Achantosis Nigricans (1)

2. blured vision +/+ (2)
3. Ttv HYPOTENSION (2)
4. Cough + ,difficult in swallowing +, (1)
5. Oedem extrimity +, pitting eddema + (1)
6. Dyspneu (1)
7. Ronkhi paru (1)
8. Cardiomegali (1)
9. Acites (1)
10. hepatomegali (1)
11.NYHA III IV (1)
12. efusi pleura (4)
13.Overweight (3)
14.TROMBUS

Laboratory
Examination
1. Hipoalbuminemia
(5)
2. Leukositosis (4)
3. Azotemia (6)

PROBLEM LIST
1. Congestive Heart Failure
2. Overweight
3. Efusi Pleura
4. Syok cardiogenic
5. Hipoalbuminemia
6. Azotemia
7. TROMBUS
8. Hiperurisemia

IP Tx

Farmacology

CONGESTIVE HEART FAILURE

Assessement
Diagnosis etiology:
hypertension, cardio
myopathy, miocarditis
Diagnosis anatomy:
LVH,RVH
Diagnosis functional:
NYHA grade 3 & 4
IP Dx

PRO NT, PRO BNP (brain

natriuretic peptide)

Furosemid 20mg 1x1

PO:

Non Farmacology

O2 canule 2-4 liter/ menit

IP Ex
Saturasi O2 <90 % Heart Helathy eating

IP Mx

Bisoprolol
Spironolakton
ARB (valsartan 40 mg)
As. folat

Maintaining Healthy
weight
Physical Activity
Condition
Stop smoking

General
Vital Sign
Chemical & hematologi sign

IP Tx

OVERWEIGHT

Assessement
IP Dx

IP Mx

Hitung kalori (90x20 = 1800

kal/ hari)
General advice on healthy
weight and life style
Consider surgery
Monitoring weight every
week
Waist circumference

IP Ex

Diet Low Calory

Diet Low Fat

IP Tx

Sesuai dengan etiologi

Transudat atau eksudat

Farmacology

EFUSI PLEURA

Antibiotics: ceftriaxon 1x1 (2gr)

Bromhexin hydroclorid 4mg/2ml
(3x1A)
Ranitidin 50mg 2x1 A

Assessement

Transudat
eksudat

IP Dx

Rivalta test

IP Mx

Non Farmacology
pungsi

Bloodtest
BGA

IP EX

Adequate restat night

Taking naps during the day if needed
Rehidration
Finishing all of their antibiotic
medications

SYOK KARDIOGENIK

Assessement
Mengatasi kegawatan

IP Dx

ECG

IP Tx
Loading cairan
dobutamin 5mcg/kgbb
Epineprin 3A
Non farmakology:

O2 possitive pressure 6-8 liter/ menit

IP Mx
Vital sign
ECG
IP Ex
*

IP Tx

Farmacologic

AZOTEMIA

Assessement

IP Mx

Chronic kidney
disease
Acute renal failure

Urine product
Biokimia blood examination
Urine examination
GFR

IP Dx

USG Abdomen

Non Farmacologic
Low protein intake 0.6-0.8 g/kgw/day

140-age xBB /72 xcreatinine serum

(140-62)x90/72x1.53 = 63,7 (Low)
LFG normal : 90
LFG mild : 60-89
LFG moderate: 30-59
LFG servere : 15-29
CKD :<15

Chemical blood ex

IP Ex

Diet low salt

Diet Low protein

HYPOALBUMINEMIA

IP Tx

Assessement

Albumin 20% (50ml&100) & 25% (50ml

&100ml)
(200gr/liter x 100ml)
3,52,28 x90x0,8= 87,84

GgGA pre renal

Sindroma Nefrotik
Sirosis hepatik

IP Dx
Pitting edema

Farmacology

Non Farmacology

IP Mx

Diet tinggi protein(putih telur)

Chemical lab for albumin post koreksi

IP EX

Diit high protein

Rehidration

TROMBUS

Assessement
Mencegah kegawatan

IP Dx

IP Tx
Heparin 150.000/24jam( unfractional
heparin) resiko perdarahan lebih besar
Enoxaparin. AriXtra ( low molecul weight
heparin) resiko perdarahan lebih kecil
Vial 5000iu/ml x 5ml

Non farmakology:

Diet low fat (LDL) : vegetable, peanut, omega 3, fruit

IP Mx
Vital sign
PTT,APTT
IP Ex
Bed rest

HIPERURISEMIA

Assessment: IP Dx

IP Tx
Allopurinol 100mg ,300mg

Non farmakology:

Diet low purin

IP Mx
Biochemia blood ex. Evaluasi
post koreksi asam urat
IP Ex
Diit low purin (kacang, jeroan,
bayam,otak, ) BENJOL