Professional Documents
Culture Documents
By :
Mohamad Nuramin bin
Masrom
C 111 12 817
Patient Identity
Name
Gender
Age
: Mr. E
: Male
: 49 years old
Anamnesis (1)
Chief Complaint
: Shortness of breath
Shortness of breath has been experienced
since 2 months ago and worsen 3 days
before entering RSWS. It was experienced
while doing minimal activity such as
walking to the bathroom and relieved with
resting. There is complain of sudden
shortness of breath during night time that
cause her to be awaken. He also had to use
at least 2 pillows to sleep during night time.
Anamnesis (2)
There is also history of chest pain which has
Risk Factors
Cigarette smoking (+)
Alcohol consumption(-)
Hypertension(+)
Diabetes Mellitus(+)
Cardiovascular disease (+)
Thyroid disease (-)
History of cardiovascular disease and
Physical Examination
General Status:
Severe ill
Nutritional Status: Good
Consciousness: Conscious
Vital Signs:
Blood Pressure : 130/90 mmHg
Pulse Rate
: 78 bpm, regular
Respiratory Rate : 26 bpm
Temperature
: 36.5 C
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 : (positive) regio
mediobasal at
Physical Examination
Cardiac Examination
Inspection
Physical Examination
Abdominal Examination
Inspection
Extremities Examination
Pretibial edema -/ Dorsum pedis edema -/-
Electrocardiography(ECG)
Interpretation:
Rhythm: sinus
HR/QRS rate:75
x/minutes
Regularity: regular
P wave & PR
interval: 0,08s and
0,2 s
QRS Complex: 2
small
squares(0.08s),
Axis: Normal
ST segment: St
depression on V5
and V6
T wave: Normal
Conclusion of ECG
Sinus rhythm, HR 75 bpm, reguler ,
Chest X-rays
Interpretation :
Suprahilar vascular dilatation at right and
left lung
Cor expand with CTI 0,72 with aorta
dilatation
Sinus diafragma sharp and bones intact
Conclusion :
Cardiomegaly with sign of pulmonary edema
with dilatation and elongation aortae
Echocardiography
Echocradiography (02/10/2016)
Left systolic ventricle function normal, fraction ejection 60%
Heart chamber dimension : In normal state
Left ventricle hypertrophy: Negative (LVMI 175.72,RWT :0.56g/m2)
Miocard movement :global normokinetik
Heart Valve: Mitral : MR Trivial
Aorta ,Trikuspid, Pulmonal : Function and movement good
Conclusion :
Left systolic ventricle function normal, ejeksi fraksi 60%
LV dilation
LVH consentric
Disfungstion diastolic grade II
Laboratory Finding
Result
Normal value
WBC
13.6/ul
RBC
2.77/l
HGB
7.9 gr/dl
12 16
HCT
36.0%
37 48
PLT
348 000/l
Test
Result
Normal value
Na
138 mmol/l
136-145
4.8 mmol/l
3.5-5.1
Cl
100 mmol/l
97-111
Electrolyte
Laboratory Finding
Blood Chemistry
Test
Result
Normal value
GDS
156 mg/dl
<140
Ureum
194 mg/dl
10 50
Creatinine
7.42 mgr/dl
< 1.3
SGOT
17 u/l
<38
SGPT
13 u/l
<41
Total Chol
HDL Chol
LDL Chol
183 mg/dl
45 mg/dl
108 mg/dl
<200
> 55
< 130
TG
75 mg/dl
<200
Test
Result
Normal value
CK
402 U/L
<167
CK-MB
31.6 U/L
<25
Troponin-T
<0.1
Negative
Cardiac Enzymes
Diagnosis
CHF NYHA III e.c CAD
Hypertensive Heart Disease
Diabetis Mellitus type II
Acute Kideney injury dd Acute
Management
O23-4lpm
IVFD Nacl 0,9% 10 tpm
Furosemid 40mg/12hours/iv
Aspilet 80mg/24hours//oral
Simvastatin 20mg/24hours//oral
Nitrokaf r 2,5mg/12hours//oral
Ramipril 2,5mg/24hours//oral
Amlodipin 10mg/24hours//oral
Alprazolam 0,5mg/24hours//oral
Levemir 0-0-10 IU
Novorapid 8-8-8 IU
Planning
Consultation with Kidney and
Hypertension Division
ECG control
Echocardiography
DISCUSSION
Congestive Heart Failure
(CHF)
Definition
Heart Failure
Congestive
Heart Failure
The
state
in
which
abnormal
circulatory
congestion occurs as the
result of heart failure.
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
Paroxysmal Nocturnal
Dyspnea
Cardiomegaly
Gallop S3
Minor Criteria
Extremity edema
Nocturnal cough
Decreased vital
pulmonary
Hepatojugular reflux
Increased of JVP
Hepatomegaly
Rales or ronchi
Pleural effusion
Tachycardia ( 120bpm)
Dyspnea deffort
sec)
Weigh loss 4,5 kg in 5 days in
response to treatment of CHF
Classification of CHF
Pathophysiology of CHF
Plaque in
coronary artery
Blood flow to
heart muscle is
reduced. Heart
muscle lacking
of oxygen
Ischemia of
heart muscle
can lead to
myocardial
infarction
Symptomatic
Congestive
Heart Failure
Pulmonary
edema
Abnormal
Heart rhythm
The heart
muscle cant
pump
adequately
Treatment of CHF
Managing
preload
Managing
contractility
Inotropic agents :
Cardiac glycosides
B- adrenergic
Phosphodiesterase
inhibitors
Diuretics
venodilator
Managing
afterload
Neurohormonal
modulation
ACE inhibitors
Angiotensin
receptor
blocker
blockers
CCB
blockers
ACE inhibitors
Angiotensin
receptor blockers
Pharmacologic Management
ACE Inhibitors
Blocks the conversion of angiotensin I to
angiotensin II; prevents functional deterioration
Recommended for all heart failure patients
Relieves symptoms and improves exercise
tolerance
Reduces risk of death and decreases disease
progression
Benefits may not be apparent for 1-2 months after
initiation
Angiotensin-Converting
Enzyme Inhibitors
Recommended as first-line therapy
Should be uptitrated to the dosages shown to be effective
and angioedema
Diuretics
Essential for symptomatic treatment when fluid
ACE inhibitor
Diuretic
Beta-blocker
Aldosterone
Antagonist
Asymptomatic LV
dysfunction
Indicated
Not indicated
Post MI
Not indicated
Symptomatic HF
(NYHA II)
Indicated
Indicated if
Fluid retention
Indicated
Not indicated
Worsening HF
(NYHA III-IV)
Indicated
Indicated
comb. diuretic
Indicated
End-stage HF
(NYHA IV)
Indicated
Indicated
comb. diuretic
Indicated
Indicated
Indicated
Angiotensin
II receptor
antagonists
Asymptomatic LV
dysfunction
Not indicated
Cardiac glycosides
Vasodilator
(hydralazine/
isosorbide
dinitrate)
Potassium
-sparing diuretic
With AF
Not indicated
Not indicated
(a) when AF
If ACE inhibitors
If ACE inhibitors
(b)
when
improved
are not tolerated
and angiotensin
Symptomatic HF (NYHA II)
from
more
and not on betaII antagonists
severe
HF
in
blockade
are not tolerated
sinus rhythm
If ACE inhibitors
are not tolerated
Worsening HF (NYHA III-IV)
and not on betablockade
End-stage HF (NYHA IV)
If ACE inhibitors
are not tolerated
and not on betablockade
If persisting
hypokalaemia
indicated
If ACE inhibitors
and angiotensin
II antagonists
are not tolerated
If persisting
hypokalaemia
indicated
If ACE inhibitors
and angiotensin
II antagonists
are not tolerated
If persisting
hypokalaemia
Guidelines for the diagnosis and treatment of chronic heart failureEuropean Heart Journal (2001) 22,
1527-1560
Coronary Artery
Disease
Coronary artery disease is a narrowing of
the
small blood vessels that supply blood and oxygen
to the heart.
(CAD) occurs when the arteries that supply blood
to the heart muscle (the coronary arteries)
become hardened and narrowed due to buildup of
a material called plaque (plaque) on their inner
walls. This is known as atherosclerosis
Eventually, blood flow to the heart muscle is
reduced, and, because blood carries much-needed
oxygen, the heart muscle is not able to receive
the amount of oxygen it needs.
Risk factors
Risk Factors That Cannot Be Modified:
Age and gender. As get older, risk for
CAD increases.
Men, risk increases after age 45.
Women, risk increases after age 55
(or menopause).
Family history of early heart disease.
Heart disease diagnosed before age
55 in father or brother.
Heart disease diagnosed before
age 65 in mother or sister.
INVESTIGATION
Electrocardiogram (ECG)
Treadmill Test
Echocardiography
Coronary Angiography
Multi-Slice Computed Tomography
Scan (MSCT)
Cardiac Magnetic Resonance Imaging
(Cardiac MRI)
Radionuclear Medicine
TREATMENT (1)
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 (2)
Special Procedures
Angioplasty (PTCA)
Coronary artery bypass surgery
Enhanced External Counterpulsation (EECP)
Cardiac Rehabilitation
Exercise training
Education, counseling, and training
THANK YOU