Heart Failure e.

c Coronary
Heart Disease
Norsikawaty Haya
Case presentation

Patient Identitiy
Name

: Mirs. N
Age
: 66 years old
MR
: 237766
Address : Barukang Street, Makassar

History taking
Chief

complaint : shortness of breath

History taking :
The patient came to RSWS with a chief
complaint shortness of breath, it occurs since 5
days ago. It happened if she was getting a rest
and activity. Sometimes the patient waked up at
night due to shortness of breath. The patient
also had nausea, vomit, and lost appetite. She
also felt waist pain like something creep on
there.
Urinate and defecate was normal.

Past medical history

She

entered Stella Maris with nerve

disturbance on 1984
She has got hypertention and diabetes
mellitus a year ago. She had a regular
medicine.
She also had opname history with a same
complaint a year ago.

Risk factor
She

had hypertention and diabetes

mellitus
She doesnt smoke and she is not
alcoholic
In her family, no one have a same disease
and there is no sudden death history.

Physical examination

Vital Sign :

Head Examination :

Blood pressure : 180/110 mmHg

Pulse
: 108/min
Breath : 32/min
Body temperature
: 36,5oC

Eyes : there is anemis. No cyanosis and no icterus

Neck : JVP R+2 cmH20

Thoracal Examination :

Inspection
: Symetric
Palpation
: no mass, no tenderness
Percussion
: Sonor
Auscultation
: Breath Sound is bronchovesikular
Additional sound : ronchi diffuse, no wheezzing

Physical examination

Heart Examination :

: ictus cordis was visible

: ictus cordis was palpable
: widening of heart size
: regular of I/II Heart Sound, no

Abdominal Examination :

Inspection
Palpation
Percussion
Auscultation
murmur

Inspection
Palpation
Percussion
Auscultation

: normal
: no mass
: tympani like sound, no acites
: peristaltic sound (+), normal

Extremity : there was no oedema at left or right legs

Additional examination

Blood Test :

: 10,3
: 332

Electrolyte :

Hb
GDS

Na
K: 4,5
Cl

: 134
: 99

Liver Function Test :

SGOT : 28
SGPT : 81

Additional examination
Lipid

Profile Test :

Total

Cholesterol
HDL Cholesterol
LDL Cholesterol
Triglyceride
Urine

Test :

Ureum
Creatinin
Uric

: 258
: 41
: 188
: 147

Acid

: 82
: 1,7
: 6,9

Electrocardiography
Tachycardia

sinus
Heart Rate : 110 bpm
Poor R-wave, V1-V5
LBBB

Suggestion additional examination

Chest

X-Ray
Echocardiogram

Management
Oxygen

4-6 litre
Heart diet
IVFD NaCl 0,9% : 12 dpm
Lasix 2 amp/12 hours/IV
Nitrocyn 20 mg
Captopril 12,5 mg 1-0-1
Aspilet 80 mg 0-1-0
Spironolakton 25 0-2-0

Diagnose
Heart

Failure e.c Coronary Heart Disease

(CHD)
DM type 2

Discussion
Heart

failure is the pathophysiologic state in

which the heart, fails to pump blood with the
requirements of metabolism of tissues and/or
pumps only from an abnormally elevated
diastolic filling pressure.
Heart failure may be caused by myocardial
failure, like myocardial infarction, termhypertention or cardiomyopathy
In certainly condition, even the myocard have a
good contractility, it cant fulfill the systemic need
blood for body metabolism.

Patomechanism
Inadequate

adaptation of the cardiac

myocytes to increased wall stress in order
to maintain adequate cardiac output
following myocardial injury
Most important among these adaptations
are the (1) Frank-starling mechanism, (2)
Myocardial hypertrophy, (3) Activation of
neurohumoral systems

Discussion
Coronary

Heart disease (CHD) is narrowing of

the small blood vessel that supply blood and
oxygen to the heart. CHD is also called coronary
artery disease
CHD is usually caused by a condition called
atherosclerosis, which occurs when fatty
material and a substance called plaque builds
up on the walls of the arteries.
As the coronary arteries narrow, blood flow to
the heart can slow down or stop, causing chest
pain (stable angina), shortness of breath, heart
attack, and other symptoms.