Congestive Heart Failure with Acute Kidney Injury

Dessy Esa S 030.08.074

Identity
Name Age Gender Adress Occupation Religion Marital status Race Education : Mr. U : 49 years : Men : Dusun Krajan, Kec. Cimalaya, Karawang : Labor : Moslem : Married : Sundanese : Elementary school

Admisson to hospital at Oct, 22th 2012

ANAMNESE
Autoanamnese on Oct 22th 2012 at 8 pm

Main complain

Shortness of breath

Additional complain

Irregular heartbeat (palpitation) Burned feelings Swelling feet Nausea, vomit, cough, and dizziness

History of present disease

Patient came to UGD of RSUD Karawang with shortness of breathing since 3 monthes ago before admitted to the hospital. But it was not currently occured, it could happens when he does the activity( walk upstair) but more when he lay down. For relief the symptom, patient usually uses three pillows while hes sleeping. Patient aslo said that he got palpitation sometimes with or without do the activity, also the burned feelings which was coming from the epigastric to the left chest and ending at both sides of his back.

A week before hospitalized, he also complains about his swelling feet which getting worse, they have relieved. The other symptoms such as fever, dry cough, nausea, and vomit were happening but now they all have relieved .

Patient has 3 times went to the doctor for the same symptoms. He has been given the meds by the doctor but the symptoms were still happening.

History of past disease

Same disease (-) Liver disease (-)

Asthma (-)

Allergy (-)

Heart disease (-) hipertension (-)

Kidney disease (-) Diabetes mellitus (-)

Maag (-)

Family history
No one in his family got a symptom or disease like him

Hypertension (-), Maag (-), Liver disease (-), Kidney disease (-), Cancer (-), Diabetes Mellitus (-)

Habitual history
Patient quits smoke since he got sick. Hes not an alcoholic and never use herbal therapy. He eats 2-3x times a day Rarely do the exercise

Picture of patient

General condition
Appereance : Moderate ill

Conciusness
Nutrition -

: Compos mentis
: Normal

Weight : 48kgs Height : 150cms BMI : 21,33

Blood pressure 110/70 MmHg VITAL SIGN

Respiration rate 24 x/min

Heart rate 112 x/min

Temperature
39,4 C

Head Eyes Ears

Normochepaly, black hair, good distribution

Anemic conjungtiva -/-, Icteric sclera +/+

Hiperemic (-/-), tenderness (-/-), secret (+/+)

Nose Mouth
Neck

Septum deviation (-), hiperemic concha (-/-), secret (-/-), mass (-/-), nostril breathing (-)

Red lip (+) dry (-). Carries (+) on M1-2 left and right. Tongue (N). Arcus faring (N). Tonsil (N). Posterior Pharyng (N)

Limf node: enlargement (-), tenderness (-) Thyroid: enlargement (-), tenderness (-) JVP: 5+1 cmH2O

THORAX
INSPECTION Ictus cordis is invisible PALPATION
Ictus cordis is palpable at 6th ICS 3 cm lat LMCS

PERCUSSION
Enlargement of the heart, shifting left border of the heart AUSCULTATION
Regular I - II absence of murmurs and gallop in hearts sound

THORAX
Inspection

: Symmetrical Palpation : Equal vocal resonance Percussion : Sonor in both lungs Auscultation : Vesicular breath sound in both lung,ronchi (-/-),wheezing (-/-)

ABDOMEN
INSPECTION
brown skin, symetrical, supple, flat Icteric (-), Caput medusae (-), spider nevi (-)

AUSCULTATION
Bowel sound (+) , venous hum (-), arterial bruit (-)

PERCUSSION
Shifting dullnes (-)

PALPATION
Hepatomegali (+)right lobe enlarges 6 cm b.a.c left lobe enlarges 8 cm below processus xyphoideus Splenomegali (-) Tenderness (+) bowel sound(+)

EXTREMITY
Warm acral
+
+

+
+

Edema

Deformation (-), brown skin , spider nevi (-), palmar erythema (-), pale (-), icteric (-), flapping tremor (-), sweeling on both knee and painfull

Laboratory test Oct 22th,2012

test Hematologi hasil Nilai normal

Hemoglobin
Leukocytes Trombocytes Hematocrite Kimia darah GDS/reduksi Ureum Creatinin SGOT SGPT

12,1
16.900 382.000 37 41 50,1 1,88 28 23

(12-17)%
(5rb-10rb) (150-450)rb (37-48)% (80-140) (10-45)mg/dl (0,4-1,5)mg/dl (<40) (<40)

Laboratory test Oct 23th, 2012

Test Hematologi Hemoglobin Leukocytes Trombocytes Hematocrite Kimia darah GDS/ Reduksi Ureum Creatinin 104 146,2 2,71 (80-140)mg/dl (10-45)mgldl (0,4-1,5)mg/dl 12,0 4.600 174.000 36 (12-17)g% (5.000-10.000) (150-450)rb (37-48)% hasil Nilai normal

Laboratory test Oct 24th, 2012

test
Ureum creatinin

hasil
129,9 2,48

Nilai normal
(10-45)mg/dl (0,4-1,5)mg/dl

Rontgen Thorax
CTR > 50% Enlargement of Left Ventricle Enlargement of Right Ventricle Enlargement of Left Atrium

Electrocardiogram

Echocardiogram

resume
Anamnese
Shortness of breath when do the activity and more when laying down 3 months ago Palpitation Dry cough Swelling feet

Physical examination
LVH by percussion Hepatomegaly Pitting oedem at lower extrimities

Laboratory, EKG, X-ray, Echocardiogram

CTR > 50% Enlargement of Left Ventricle Enlargement of Right Ventricle Enlargement of Left Atrium EKG Clockwise rotation Left atrial overload ECG CAD HHD EF 25% LVH consentric Left ventricle function << Diastolic disfucntion gr. 1 AR mild, MR moderate Leukocytes= 16.900 Ureum = 129,9 Creatinin= 2,48

Differential Diagnoses
CHF NYHA 2 e.c Coronary Artery Disease and Hypertension Heart Disease CHF NYHA 2 e.c Susp. RHD CHF NYHA 2 e.c Cardiomyopathy Acute Kidney Injury Chronic Kidney Disease

Working diagnose
Congestive Heart Failure et Causa Coronary Heart Disease and Hypertension Heart Disease with Acute Kidney Injury.

Suggested examination
urinalysis

electrolyte

ASTO

BNP

Profil lipid

therapy
Non-farmakologis Internist
Education (definition and symptoms, how and when to use the drugs) IVFD D5%+lasix 10amp(drip) 8dpm

Cardiologist
Furosemide 2x1amp

Avoid risk factors

Renxamin 1 fl/day

Valsartan 1x80

Diet and exercise

Ceftriaxon 2x1

Lovenox 2x0,4cc

KSR 1x1

t. Aspilet 1x1

Clopidogrel 1x75

Simvastatin 1x20

Allprazolam 1x0,5

prognosis
Ad vitam: dubia ad bonam Ad sanationam: dubia ad malam

Ad functionam: ad malam