CHAPTER II CASE REPORT II.1 IDENTIFICATION Name Age Sex Address Status Occupation Religion : Mrs.

R : 27 years old : Female : Desa Rejodadi Kabupaten Banyuasin III : Married : House wife : Moslem

Admitted to hospital : November 5th 2008 II.2 ANAMNESIS (Autoanamnesis dan Alloanamnesis [husband]) Chief Complaint Shortness of breath again so heavy since 1 week before admission. History of illness 3 months before admission, the patient complained of having shortness of breath, it was depended on position and activity, she felt more comfortable if she sat and would feel shortness of breath after going to toilet, she felt better if she took a rest. It was not depended on weather or emotion, and not followed by mengi voice. She would be more comfortable if she slept with 23 pillows. She also complained about woke up in the night because of the shortness of breath. Heart palpitation(+). She denied any complain of chest pain, cough, fever, or over sweating at the nigth. She also complained about swelling in both of lower extremity. Swelling in palpebra superior was denied. She didnt complain about icteric in skin and eyes. She also complained about nausea and epigastrium pain, but no vomit. There was no problem in urinate and defecation. She went to RSMH and was hospitalized for 10 days until she got well.

 1 month before admission, the patient complained of having shortness of breath again, it was depended on position and activity, she felt more comfortable if she sat and would feel shortness of breath after walking 5 meters, she felt better if she took a rest. It was not depended on weather or emotion, and not followed by mengi voice. She would be more comfortable if she slept with 3-4 pillows. She also complained about woke up at night because of the shortness of breath. Heart palpitation(+). She denied any complaint of chest pain, cough, fever, or over sweating at the nigth. She also complained about swelling in both of lower extremity. Swelling in palpebra superior was denied. She didnt complain about icteric in skin and eyes. She also complained about nausea and epigastrium pain, but no vomit. There was no problem in urinate and defecation. She went to RS. Siti Khodijah and was hospitalized for 25 days until she got well. 1 week before admission, the patient complained of having shortness of breath again so heavy, it was depended on position and activity, she felt more comfortable if she sat, but she couldnt walk anymore. It was not depended on weather or emotion, and not followed by mengi voice. She would be more comfortable if she slept with 4-5 pillows. She also complained about woke up at night because of the shortness of breath. Heart palpitation (+). She denied any complaint of chest pain, cough, fever, or over sweating at the night. Swelling in palpebra superior and lower extremity was denied. She didnt complain about icteric in skin and eyes. She also complained about nausea and epigastrium pain, but no vomit. There was no problem in urinate and defecation. She went to RSMH again for these complaints. History of past illness History of heart disease since 14 years ago, hospitalized minimally once in a year History of pain in joint and bone since 10 years old History of hypertension was denied History of diabetes mellitus was denied History of kidney disease was denied

History of asthma was denied History of gastric pain since 10 years ago History of being blue when baby was denied Family Disease History History of heart disease (+) in her mother History of hypertension (+) in her mother

II.3 PHYSICAL EXAMINATION General examination General condition Sickness condition Consciousness Blood pressure Pulse rate Respiration rate Temperature Dehydration Nutrition Weight Height : sick : severe sickness : compos mentis : 90/60 mmHg : 100 times/minute, irregular : 40 times/minute : 36,90 C : (-) : RBW = 70,7% Impressive: undernutrition : 35 kg : 155 cm

Spesific examination 1. Skin Skin color is puce Normal pigmentation Efloresence, icteric, sianotic or pale on palm and plantar (-)

 Scar (-) Hyperhidrosis (-) Normal hair growth Good turgor Wet or dry in palpitation (-) Nodul subcutan (-) 2. Lymph gland There were no enlargement of the lymph nodes on submandibular, neck, axillaries and inguinal. 3. Head 4. Eye Eksophtalmus and enophtalmus (-) Edematous palpebra superior (-) Pale of conjunctiva palpebra (-) Sclera icteric (-) Oval, symmetrical Puffy face (-) Deformity (-) Malar rash (-) Alopecia (-)

5. Nose Epistaxis (-) Normal nasal septum and mucous layer 6. Ear Good hearing Normal both of meatus accusticus externus 7. Mouth

Rhagaden of lips (-) Stomatitis (-) Papil atrophy (-) Gum bleeding (-)

Fetor oris (-) 8. Neck Thyroid gland not palpable, thyroid bruit (-) Jugular vein pressure (5+2) cmH20 Hypertrophy of musculus sternocleidomastoideus (-), stiffness (-) 9. Thorax Normal shape Extended intercostal section (-) Retraction (-) Venectasis (-) Spider naevi (-) 10. Lung Inspection Palpation Percussion : symetrical of static and dynamic right and left are equal : stemfremitus is weaker on base of right lung : dull in right lung started at ICS IV, sonor on left lung

Auscultation : vesicular (+) weaker on base right lung, soft wet rales on all of left and right lung, wheezing (-) 11. Cor Inspection Palpation Percussion : ictus cordis was seen in ICS VI : ictus cordis was palpable in ICS VI, thrill (+) : upper boundary of cor is ICS III, left boundary of cor is LAA and right boundary of cor is hard to be evaluated.

Auscultation

: heart rate 110 times/minutes, irregular, murmur (+) systolic and diatolic on all of the valves, grade IV, punctum maximum is on mitral valve spread to the back, gallop (-)

12. Abdomen Inspection Palpation : flat, venectation (-), : pain (+) on epigastrium, spleen is unpalpable, liver is palpable 7 fingers under arcus costae, sharp edge, elastic consistency, flat surface, palpable pain (+) Percussion : tympany, shifting dullness (-)

Auscultation : bowel sound (+) normal not examined

13. External genitalia : 14. Upper extremity Pain on joint (+) Pale on finger (-) Erythema of palm (-) Pitting edema (-) Clubbing finger (-) Tremor (-) Normal physiological reflex

15. Lower extremity Varices (-) edema (-) Pain on joint (+) Pale on finger (-) Normal physiological reflex

II.4 ADDITIONAL EXAMINATION Electrocardiography (November 5th 2008) AF, axis normal, HR 110-140 times/minute, P wave is hard to be evaluated, PR interval is hard to be evaluated, QRS complex 0,04 seconds, R/S V1 <1, SV1 + RV1/V5/V6 > 35, S persistent in V5-V6 Impression: rapid ventriculat respond AF + LVH Laboratory Findings (November 5th 2008) Blood analysis Hemoglobin Hematocrite Leucocyte ESR Trombocyte Diff. Count BSS Cholesterol total HDL-cholesterol LDL-cholesterol Triglycerida Uric acid Ureum Creatinin Total Protein Albumin Globulin Total Bilirubin : 10,8 g/dl : 32 vol% : 6.500/mm : 30 mm/hr : 291.000 : 0/5/2/77/12/4 ( N: 0-1/1-3/2-6/50-70/20-40/2-8 ) : 105 mg/dl : 155 mg/dl : 45 mg/dl : 91 mg/dl : 96 mg/dl : 4,5 mg/dl : 18 mg/dl : 0,7 mg/dl : 6,6 gr/dl : 3,1 gr/dl : 3,5 gr/dl : 1,8 mg/dl ( N: 0,1-1 ) ( N: < 200 ) ( N: > 55 ) ( N: <130 ) ( N: < 150 ) ( N: 1,6-6,0) ( N: 15-39 ) ( N: 0,9-1,3 ) ( N: 6-7,8 ) ( N: 3,5-5 ) ( N: 14-18 g/dl ) ( N: 40-48 vol% ) ( N: 5000-10000/ mm ) ( N: < 10 mm/hr ) ( N: 200000-500000/ mm )

 Direct bilirubin

: 1,22 mg/dl

( N: <0,25 ) ( N: <0,75 ) ( N: <40 ) ( N: < 41 ) ( N: 160-320 ) ( N: 135-155 ) ( N: 3,5-5,5 )

Indirect bilirubin : 0,58 mg/dl SGOT SGPT LDH Sodium Potassium Urine Analysis Epithelial cell WBC RBC Cylinder Crystal : (+) : 0-1/LPB : 0-3/LPB : (-) : (-) : 35 U/L : 39 U/L : 266 U/L : 135 mmol/l : 5,0 mmol/l

( N: 0-5/LPB ) ( N: 0-1/LPB ) ( N: - ) ( N: - )

Rontgen thorax (November 5th 2008) The condition of the photo was good Right and left were equal Trachea was in the middle No Extended intercostal section Condition of the bone was good, no fracture CTR was difficult to seen Right costophrenicus angle was difficult to be evaluated, left costophrenicus angle was keen Right diaphragm at ICS II Parenchyme cephalization (+)

Impression: subdiaphragm process + cardiomegaly + acute lung edema

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Echocardiography (October 9, 2008) - EDO : 5,47 cm - ESO : 4,06 cm - PW : 0,65 - IVS : 0,74 - LA : 13,3 - AO : 3,04 - EF : 50,3% - FS : 25,8 - LA/AO : 4,37 Impression: MVD e.c. RHD - LV dilatation - LA dilatation - LVH (-) - LV EF 50% - MS severe, MVA = 1,76; MPG = 13-19 - MR severe - AR moderate - AS mild-moderate - TR moderate

II.5 RESUME A woman initialed name Mrs. R, 27 years old, admitted to hospital in November 5th 2008, with shortness of breath again so heavy since 1 week before admission as the chief complaint. 3 months before admission, the patient complained of having shortness of breath, it was depended on position and activity, she felt more comfortable if she sat and would feel shortness of breath after going to toilet, she felt better if she took a rest. She would be more comfortable if she slept with 23 pillows. She also complained about woke up in the night because of the shortness of breath. Heart palpitation (+).She also complained about swelling in both of lower extremity, nausea ,and epigastrium pain. She went to RSMH and was hospitalized for 10 days until she got well. 1 month before admission, the patient complained of having shortness of breath again, it was depended on position and activity, she felt more comfortable if she sat and would feel shortness of breath after walking 5 meters, she felt better if she took a rest. It was not depended on weather or emotion, and not followed by mengi voice. She would be more comfortable if she slept with 3-4 pillows. She also complained about woke up at night because of the shortness of breath. Heart

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palpitation (+). She also complained about swelling in both of lower extremity, nausea ,and epigastrium pain. She went to RS. Siti Khodijah and was hospitalized for 25 days until she got well. 1 week before admission, the patient complained of having shortness of breath again so heavy, it was depended on position and activity, she felt more comfortable if she sat, but she couldnt walk anymore. She would be more comfortable if she slept with 4-5 pillows. She also complained about woke up at night because of the shortness of breath. Heart palpitation (+). She also complained about nausea and epigastrium pain. She went to RSMH again for these complaints The patient has history of heart disease since 14 years ago, hospitalized minimal once in a year, and history of pain in joint and bone since 10 yaers old. History of heart disease and hypertension was (+) in her mother. From physical examination, the general condition of the patient was severe sickness and his consciousness was compos mentis. Blood pressure 90/60 mmHg, pulse rate 100 times/minute, irreguler, respiration rate 40 times/minute, temperature 36,90 C, RBW (weight = 35 kg and height = 155 cm) = 70,7%, impressive undernutrition, jugular vein pressure (5+0) cmH 2O. In anterior and posterior of lung examination, there was soft wet rales on both of left and right lung, while in cor examination, ictus cordis cab be seen and palpable in ICS VI, thrill (+), upper boundary of cor is ICS III, left boundary of cor is LAA, and right boundary of cor is couldnt be evaluated, heart rate 110 times/minutes, irregular, murmur (+) systolic and diatolic on mitral valve, gallop (-). While abdomen examination, liver is palpable 7 fingers under arcus costae.

Score Framingham for this patient: Major Criteria Paroksysmal noctunal dispnea Distension of neck vein Rales on pulmo (+) (-) (+) (+)/(-)

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 Cardiomegaly Acute pulmonary edema Gallop S3 Increased of JVP Refluks hepatojugular Minor Criteria Edema of extremity Cough in night time Dispnea deffort Hepatomegaly Pleural effusion Decreased of vital capacity Tachycardia (>120 times/minute) II.6 WORKING DIAGNOSIS Chronic heart failure e.c MVD e.c. RHD II.7 DIFFERENTIAL DIAGNOSIS

(+) (+) (-) (+) (+) (+)/(-) (-) (-) (+) (+) (-) (-) (-)

Chronic heart failure e.c MI/MS e.c. RHD Chronic heart failure e.c congenital valve abnormality

II.8 TREATMENT Nonpharmachology O2 3 liters/minute Bedrest (Half sat position) Cor diet III

Pharmachology IVFD D5 gtt X/minute (micro)

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Furosemide amp 1x1 Spironolactone tab 1x25 mg Digoxin 1x0,25 mg Acetosal 1x100 mg Laxadyn syr 3x1C Omeprazole tab 1x1

II.9 PLANNING Echocardiography Repeat chest X-ray Electrolite examination : dubia et malam : dubia et malam

II.10 PROGNOSIS Quo ad vitam Quo ad functionam

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II.11 FOLLOW UP
S O November 6th 2008 complaint : shortness of breath, nausea, epigastrium pain Sense Compos mentis Blood pressure 100/60 mmHg Pulse rate 100 x/menit Temperature 36,5 C Respiration rate 36 x/menit head Pale of conjunctiva palpebra (-), icteric sclera (-) neck Cor Pulmo Abdomen Extremitas A P JVP = (5+2) cmH20, Lymph gland enlargement (- )

HR = 120 x/min, irregular, murmur (+) systolic and diastolic on all of the valves, gallop (-) vesicular (+) weaker on base right lung, soft wet rales on all of left and right lung, wheezing (-) Flat, pain (+) on epigastrium, liver is palpable 7 fingers under arcus costae, bowel sound (+) normal
Edema (-)

Chronic heart failure e.c MVD e.c. RHD Nonpharmachology O2 3 liters/minute Bedrest (Half sat position) Cor diet III Pharmachology

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IVFD D5 gtt X/minute (micro) Furosemide amp 1x1 Spironolactone tab 1x25 mg Digoxin 1x0,25 mg Acetosal 1x100 mg Laxadin syr 3x1c Omeprazole tab 1x20 mg
Planning

Echocardiography, electrolytes examination

S O November 7th 2008 complaint : shortness of breath, nausea, vomit, epigastrium pain Sense Compos mentis Blood pressure 90/70 mmHg Pulse rate 68 x/menit Temperature 36,2 C Respiration rate 30 x/menit head Pale of conjunctiva palpebra (-), icteric sclera (-) neck Cor Pulmo Abdomen Extremitas A P JVP = (5+2) cmH20, Lymph gland enlargement (- )

HR = 80 x/minutes, irregular, murmur (+) systolic and diatolic on all the valves, gallop (-) vesicular (+) weaker on base right lung, soft wet rales in all of left and right lung, wheezing (-) Flat, pain (+) on epigastrium, liver is palpable 7 fingers under arcus costae, bowel sound (+) normal
Edema (-)

Chronic heart failure e.c MVD e.c. RHD Nonpharmachology O2 3 liters/minute Bedrest (Half sat position) Cor diet III Pharmachology IVFD D5 gtt X/minute (micro) Furosemide amp 1x1 Spironolactone tab 1x25 mg Digoxin 1x0,25 mg

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Acetosal 1x100 mg Laxadin syr 3x1c Omeprazole tab 1x20 mg

Planning

Echocardiography Electrolite examination

S O November 8th 2008 complaint : nausea and epigastrium pain Sense Compos mentis Blood pressure 90/60 mmHg Pulse rate 92 x/menit Temperature 36,4 C Respiration rate 24 x/menit head Pale of conjunctiva palpebra (-), icteric sclera (-) neck Cor Pulmo Abdomen Extremitas A P JVP = (5+2) cmH20, Lymph gland enlargement (- )

HR = 92 x/minutes, irregular, murmur (+) systolic and diatolic on all the valves, gallop (-) vesicular (+) weaker on base right lung, soft wet rales on the base of left and right lung, wheezing (-) Flat, pain (+) on epigastrium, liver is palpable 7 fingers under arcus costae, bowel sound (+) normal
Edema (-)

Chronic heart failure e.c MVD e.c. RHD Nonpharmachology O2 3 liters/minute Bedrest (Half sat position) Cor diet III Pharmachology IVFD D5 gtt X/minute (micro) Furosemide amp 1x1 Digoxin 1x0,25 mg Acetosal 1x100 mg Laxadyn syr 3x1c Omeprazole tab 1x1
Planning

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Echocardiography Electrolite examination

S O November 10th 2008 complaint : abdominal discomfort Sense Compos mentis Blood pressure 100/70 mmHg Pulse rate 92 x/menit Temperature 36,4 C Respiration rate 22 x/menit head Pale of conjunctiva palpebra (-), icteric sclera (-) neck Cor Pulmo Abdomen Extremitas A P JVP = (5+2) cmH20, Lymph gland enlargement (- )

HR = 92 x/minutes, irregular, murmur (+) systolic and diatolic on all the valves, gallop (-) vesicular (+) weaker on base right lung, soft wet rales on the base of left and right lung, wheezing (-) Flat, pain (+) on epigastrium, liver is palpable 7 fingers under arcus costae, bowel sound (+) normal
Edema (-)

Chronic heart failure e.c MVD e.c. RHD Nonpharmachology O2 3 liters/minute Bedrest (Half sat position) Cor diet III Pharmachology IVFD D5 gtt X/minute (micro) Furosemide amp 1x1 Digoxin 1x0,25 mg Acetosal 1x100 mg Laxadin syr 3x1c Omeprazole tab 1x1
Planning

Echocardiography Electrolite examination

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