CHF NYHA III-IV ec MS

Nila Daniati Latief

C11103076

IDENTITY OF PATIENT
Name
Age
Religion
MR
Address
Occupation

: Mrs.SS
: 56 years old
: Islam
: 340256
: Bantaeng
: Housewife

History Taking
Mrs. SS, 56 years old admitted to the hospital with main
complain of dyspnea since 2 weeks ago.It has been
getting worse since 2 days ago, continously, influenced
by activity but sometimes occur when she was rest. She
sometimes sleeps by using 1-2 pillows. She sometimes
wakes up at midnight because of dispnea. Chest pain (-),
throb (+), fever (-), headache (-), cough (-), nausea (-),
vomiting (-), epigastric pain (+), fatigue (+).

Past illness history

Hypertension (+). It has been known since 1 years

ago, control regulated

Diabetes Melitus (-)
She has been treated at Wahidin Hospital for 4
times with the same complain and diagnosed by
doctor with cardiac valve disease
Rheumatic (+)

Physical Examination
SP
: Severe illness / underweight / conscious
Vital Sign : Blood Pressure
= 140/90 mmHg

Head
Neck
Thorax

Pulse
= 110 x/min, irregular
Respiratory Rate
= 36 x/min
Temperature = 36,5 oC
: Anemia (+) jaundice (-) cyanosis (-)
: JVP = R+1 cm H2O
: Breath Sound = Vesicular
Additional Sound = Rh +/+, wh -/-

Physical Examination
Cor :

I = Ictus cordis is seen 2 finger at lateral of

Left Medioclavicular line
P= Ictus cordis is palpable 2 finger at lateral of
Left Medioclavicular line, diastolic thrills (+)
P= Dullness, cardiac impression is widely
to the lateral of Left Medioclavicular line
A= Heart Sounds = I/II irregular irregularity
Diastolic murmur (+) grade 2/4
Abdomen : Hepar and spleen unpalpable
Extremities : Edema -/-

Electrocardiography

Electrocardiography

Electrocardiography

Electrocardiogram (ECG)
Conclusion :
Sinus Dysritmia, HR 110 x/min
Atrial Fibrilation Rapid Ventricular Respon
Anteroseptal myocardial ischemia

Working Diagnosis
CHF NYHA III-IV e.c. MS

Laboratory Examination

WBC
RBC
HGB
HCT
PLT
GDS
Ureum
Kreatinin
SGOT
SGPT
CK
CK-MB

: 11.600 /L
: 3.670.000 /L
: 10,5 gr/dl
: 43,5 %
: 231.000 /L
: 134 mg/dL
: 47 mg/dL
: 1,0 mg/dL
: 19 U/l
: 14 U/l
: 121
: 15

Na
K
Cl

: 119 mmol/l
: 3,4 mmol/l
: 91 mmol/l

X-ray Thorax
Impression:
Cardiomegaly (CTI > 50%)
There is no active specific
process in both of
hemithoraks

Echocardiography
Dilatation of LA

Contractilytas of LV is good, EF 66 %
MS Moderate, MVA 1,1 cm2
TI, PH (PAP 25 mmHg)
Conclusion :
MS, PH, TI

Therapy
O2 3-4 L/min
IVFD NaCl 0,9% 16 drips/min
Furosemid 20mg/12 hours
Spironolactone 25 mg 1-1-0
Digoxin 0,25mg/bolus iv,
and then digoxin 0,25 mg 1 x 1
Ranitidine 1 amp/12 hours
Aspilets 80 mg 0-1-0
Na correction with NaCl 3 % 1,4 kolf

DISCUSSION

Mitral Stenosis
Mitral stenosis is a heart valve disorder that

involves a narrowing or blockage of the opening

of the mitral valve, which separates the upper
and lower chambers on the left side of the heart

Etiology
The most common cause of mitral stenosis is

Rheumatic fever (>90 %).

Non Rheumatic Fever

Pathology
Rheumatic Fever
Healing
Leaflets adhere at comissures of mitral valve
Fibrosis and calcification
rigid

Pathophysiology
Mitral Stenosis
Increase of left atrium pressure
Enlargement of left atrium
Congestive of pulmonal vein
Increase of pulmonal artery pressure
Increase of right ventricle pressure
Increase of right atrium pressure
Enlargement of right atrium
Congestive of systemic veins

Degree of Mitral Stenosis

Normal valve area: 4-6 cm2
Mild mitral stenosis:

MVA 1.5-2.5 cm2

Minimal symptoms

Moderate mitral stenosis

MVA 1.0-1.5 cm2

Usually doesnt cause symptoms at rest

Severe mitral stenosis

MVA < 1.0 cm2

Symptoms
Dyspnea
Orthopnea
Paroxysmal nocturnal dyspnea
Tachycardia
Haemoptysis
Palpitation
Cough
Chest Pain
Abdominal discomfort
Oedema of the legs

Physical Sign

The arterial pulse irregular

Increase of JVP
Limit of cardiac is wide
Ascites
Hepatomegaly
A loud first heart sound
An opening snap
A mid-diastolic murmur
A presystolic murmur

X-Ray Thorax
Left Atrial Hypertrophy
Right Ventricle Hypertrophy
Oedema pulmonal

Electrocardiogram (ECG)
P mitral
Right Axis Deviation
Atrial Fibrillation
Left Atrial Enlargement
Right Ventricular Hypertrophy

Echocardiography
Mitral Stenosis
Pulmonal Hypertension
Tricuspid Insuficiency
Left atrial thrombosis

Treatment
Diuretic
Cardiac Glycoside (Digoxin)
Antithrombotic (Acetyl Salysilic Acid)
PBMV ( Percutaneous Ballon Mitral

Valvuloplasty)
Mitral Comissurotomy
Mitral Valve Replacement