SITI NUR AIN BT ZULKIFLI C 111 07 380

Supervisor:
dr. Pendrik Tandean , Sp.PD
 Name : Mr. MA
Age : 40 yo
Gender : Male
Address : P. Kodingareng ujung tanah
MR : 530528
Room : L1 BD K2/III
Admitted : January 17th 2012
 CC: Shortness of breath
It has been experienced since 3 months ago and
worsen a month before admitted to the hospital.
This complain worsen if patient doing mild
activity such as walking.
Orthopnea (+) PND (+)
Chest pain (-) History of chest pain (-)
History of same complain before (-)
History of chronic cough (-) palpitation (-)
History of fever accompany with joint pain (-)
History of hypertension and diabetes mellitus (-)
History of smoking (+) >20 years (1/2 pack / day)
Present status:
Moderate illness / Well-nourished /
Conscious

Vital signs:
BP : 120/80 mmHg
HR : 88 bpm
RR : 28 tpm
T : 36,8C (axilla)
Head : Anemia(-)Icterus(-)Cyanosis ( - )
Neck : No mass, no tenderness,
JVP R+4 cmH2O
Chest :
Inspection : symmetric
Palpation : no mass, no tenderness
Percussion : sonor
Auscultation : vesicular,
Rh +/+ (basal) Wh -/-
Heart:
Inspection : Ictus cordis visible at 6th ICS,
2 cm lateral from left MC line
Palpation : Apex palpable, thrill (+)
Percussion :
- left border : 2 cm lateral from MC line
- right border : Ln. parasternalis dextra
Auscultation :
- S1/S2 regular,
- diastolic murmur grades III/IV pm, left
parasternal ics 3-4
Abdominal :
Inspection : convex, moving with
respiration
Palpation : hepar & spleen were hard to
examine
Percussion : undulation (+)
Auscultation : peristaltic sound (+)
normal

Extremities :
Edema +/+ at pretibial and dorsum pedis
Result:
Cardiomegaly with
pulmonary oedema
 TEST RESULT
January 17th 2012
WBC 8,94 x 103
RBC 4,64 x 103
HGB 15,5
HCT 42,2
PLT 143 x 103
MCV 90,9
MCH 33,4
MCHC 36,7
NATRIUM 123
KALIUM 2,8
CHLORIDE 80
 TEST RESULT
January 17th 2012
RANDOM BLOOD 105
GLUCOSE
UREUM 33
CREATININE 0,8
TOTAL BILIRUBIN 6,5
DIRECT BILIRUBIN 3,2
GOT/GPT 48/24
TOTAL PROTEIN 5,2
ALBUMIN 3,4
GLOBULIN 1,8
CK 176
CK-MB 18
TROPONIN T Negative
 TEST RESULT
January 17th 2012
PT 15,2
INR 1,2
APTT 26,0
January 19th 2012
GOT/GPT 49/27
UR/KR 51/1,05
CT 800
BT 200
PT 19,4 control 11,0
INR 1,65
APTT 33,2 control 26,4
D DIMER 0,80
TEST RESULT
January 19th 2012
WBC 9,94 x 103
RBC 4,5 x 103
HGB 15,0
HCT 41,0
PLT 129 x 103
MCV 91,1
MCH 33,3
MCHC 36,6
 TEST RESULT TEST RESULT
URINALISA January 20th 2012
Colour Yellow Leucocytes 100
pH 5 Blood 250
BJ 1,020 Vit C Negative
Protein 75 Erythrocyte sediment >100
Glucose Normal Leucocyte sediment 2
Bilirubine 1 Torak sediment -
Urobilinogen 4 Crystal sediment -
Ketone Negative Ephitelial cell sediment 2
Nitrite Positive Other sediment Bacteria +++
 TEST RESULT
January 26th 2012
TOTAL BILIRUBINE 4,04
DIRECT BILIRUBINE 2,64
TOTAL PROTEIN 5,3
ALBUMIN 3,1
GLOBULIN 2,2
NATRIUM 127
KALIUM 4,2
CHLORIDE 94
 Systolic function of LV is good, EF 78 %
Stenosis mitral severe
Regurgitation Aorta moderate
Regurgitation Tricuspid severe
Regurgitation Pulmonal moderate
Minimal Pericardial effusion
Congestive liver
Ascites
Left pleural effusion
 CHF NYHA III ec
MITRAL STENOSIS
 O2 3-4 lpm via nasal canule
IVFD NS 10 dpm
Inj furosemid 20 mg/12 jam/IV
Spironolacton 25mg 1-1-1
Aspilet 80mg 1-0-0
Congestive Heart Failure is a
patophysiological state lead to cardiac
output decrease or congestion of
pulmonary and systemic vein with
abnormalities of cardiac function to pump
blood at a rate commensurate with the
requirements of the metabolizing tissues.
 II. Mild symptoms and
I.No symptoms and no
slight limitation during
limitation in ordinary
ordinary activity.
physical activity.
Comfortable at rest.

III. Marked limitation in

activity due to symptoms, IV. Severe limitations.
even during less-than- Experiences symptoms
ordinary activity. even while at rest.
Comfortable only at rest.
 Ischemic heart
disease (40%)
Others (5%)

Hypertensive
Cardiomyopathy
heart disease
(32%)
(11%)

Valvular heart
disease (12%)
Left-side Right-side
Failure Failure

dyspneu
hepatomegaly
deffort

orthopneu ascites

paroxysmal
nocturnal nocturia
dyspneu

oedema
dizziness
pretibial

confusion coagulopathy
Left-side Right-side
Failure Failure

rales on the jugular venous

basal lung pressure

pulmonary hepatojugular
edema reflux

pleural parasternal
effusion heave

cyanosis

gallop rhythm
 peripheral edema
jugular venous distention
Tachycardia
Tachypnea
Hypertension
Pulsus alternans
Wheezing or rales may be heard on lung
auscultation.
Apical impulse frequently is displaced laterally.
Cardiac auscultation may reveal aortic or mitral
valvular abnormalities, S3 or S4.
Framingham Criteria

NB : To establish a clinical diagnosis of congestive heart failure by these criteria, at

least one major and two minor criteria are required.
General advice and measures
Educating patients and family
Weight control (consult the doctor if their weight
increases)
Dietary measures (sodium should be limited to
below 2000 mg daily,
Alcohol intake should generally be nil, but should
not exceed 10-20 g/day
Smoking should be strongly discourage
Travelling (long flights may predispose to an
exacerbation of CHF)
discourage major emotional
Advice on immunizations (Influenza,
pneumococcal disease)
Drug counselling/ drugs to avoid or beware
 First- Angiotensin-converting enzyme (ACE)
inhibitors

line Diuretics
Beta-adrenoceptor antagonists
Aldosterone receptor antagonists
agents Angiotensin receptor antagonists

Second- Cardiac glycosides

Vasodilator agents (nitrates/hydralazine)

line Positive inotropic agents

Anticoagulation
Antiarrhythmic agents
agents Oxygen
 Revascularization (catheter interventions
and surgery), other forms of surgery
Pacemakers
Implantable cardioverter defibrillation
(ICD)
Heart transplantation, ventricular assist
devices, artificial heart
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
 The most common cause of mitral stenosis is
Rheumatic fever (>90 %)

Non Rheumatic Fever

- congenital mitral stenosis,
- systemic lupus erythematosus (SLE)
- rheumatoid arthritis (RA),
- myxoma atrial
- bacterial endocarditis
 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
 Normal valve
area: 4-6 cm2
Mild mitral MVA 1.5-2.5 cm2
stenosis: Minimal symptoms

MVA 1.0-1.5 cm2

Moderate mitral
Usually doesnt cause
stenosis symptoms at rest

Severe mitral MVA < 1.0 cm2

stenosis
Severity Symptoms
Mild Asymptomatic or mild DOE
Moderate Mild-mod DOE; orthopnea, PND, hemoptysis

Severe Dyspnea at rest; possible pulmonary edema

Very Severe Severe PHT; RV failure, marked dyspnea at rest;

severe fatigue; cyanosis

Dyspnea Tachycardia Abdominal

Orthopnea Haemoptysis discomfort
Paroxysmal Palpitation Oedema of the
nocturnal Cough legs
dyspnea Chest Pain
 Inspection
Malar flush
Peripheral cyanosis (severe MS)
Jugular venous distension (right ventricular failure)

Palpation
Parasternal right ventricular impulse
Palpable pulmonary arterial impulse
Palpable S1, P2, and occasionally, the diastolic rumble

Auscultation
Increased intensity of the first heart sound
Opening snap
Low-pitched diastolic rumbling murmur

The arterial Hepatomegaly murmur

pulse irregular A loud first A presystolic
Increase of JVP heart sound murmur
Limit of cardiac An opening
is wide snap
Ascites A mid-diastolic
 Left Atrial
Hypertrophy
Pulmonal Atrial
Dilatation
Right Ventricle
Hypertrophy
Oedema
pulmonal
 P mitral Right Ventricular
Right Axis Deviation Hypertrophy
Atrial Fibrillation
Left Atrial Enlargement
 Mitral Stenosis
Pulmonal Hypertension
Tricuspid Insuficiency
Left atrial thrombosis
 Diuretic
Cardiac Glycoside (Digoxin)
Antithrombotic (Acetyl Salysilic Acid)
PBMV ( Percutaneous Ballon Mitral
Valvuloplasty)
Mitral Comissurotomy
Mitral Valve Replacement