C A S E P R E S E N TAT I O N

Present by
Hazmi Adly Harun Bin Harun
(C111 11 828)

Supervisor :
Prof dr Peter Kabo PhD SpFK SpJP(K) FIHA FASCC

Department of Cardiology and Vascular Medicine

Medical Faculty of Hasanuddin University
Makassar 2015
 PATIENT IDENTITY
• Name : Mr S
• Age : 56 years old
• Gender : Male
• Admission date : 09-03-2016
 HISTORY TAKING
Chief Complaint : Shortness of breath

• Felt since approx. 2 weeks ago and worsen 2 days before being admitted to the
hospital. Experienced while doing minimal activity such as walking to the bathroom
and is relieved with rest.
• At times patient get startled during the night due to sudden onset of shortness of
breath.
• Patient usually sleeps using more than 1 pillow
• No chest pain
• Heartburn (-)
• Cough (-).
• Swelling extremities/ edemas (+)
 Past Medical History

* History of hypertension (-)

* History of diabetes mellitus (-)
* History of family members with same illness (-)
* History of smoking (+), approx. 2 boxes of cigarette
a day
* History of concumption of alcohol (+)
Family History

History of cardiovascular disease in family (-)

 RISK FACTORS

Non- Modified Modified

• Smoking
• Alcohol consumption
General Status
* Moderate illness/ Well nourished/ Conscious
* Nutritional Status: Normal
* Weight : 67 kg
* Height : 163 cm
* BMI : 25.21 kg/m2

Vital Sign

* Blood Pressure : 90/60 mmHg

* Pulse Rate : 82 bpm
* Respiratory Rate : 26 bpm
* Temperature : 36.6 0C (axilla)
 PHYSICAL EXAMINATION

Head and Neck Examinations

Eye : Conjunctiva anemic (-/-), Sclera icteric (-/-)
Lip : Cyanosis (-)
Neck : JVP R +3 cmH₂O

Chest Examination
Inspection : Symmetric between left and right chest.
Palpation : No mass, no tenderness.
Percussion : Sonor between left and right chest, lung-
liver border is ICS IV right anterior.
Auscultation: Respiratory sound: Vesicular
Additional sound :Ronchi +/+ mediobasal,Wheezing -/-
 • Inspection : Heart apex not visible
• Palpation : Heart apex palpable
• Percussion : Heart borders elongates
• Auscultation : S I/II regular, murmur pansystolic

Heart
• Inspection : Distended, follows breathing movement
• Auscultation : Peristaltic sound (+), normal
• Palpation : No mass, no tenderness, liver palpable
4cm from arcus costa and spleen unpalpable
• Percussion : Tympani (+)
Abdomen

• Pretibial edema +/+

• Dorsal pedis edema +/+

Extremities
 ECG
interpretation
* Rhythm : Sinus rhythm
* Heart rate : 88 bpm
* Regularity : reguler
* Axis : Normoaxis
* P wave : 0,06 s
* PR interval : 0,08 s
* QRS complex : duration 0,10s,
* ST Segment : 0,12 s
* Conclution :
Sinus rhythm, HR 88 bpm, regular, Normoaxis, LVH
INTERPRETATION of CHEST X RAY
• Cardiomegaly with signs of
pulmonary edema

INTERPRETATION OF ECHOCARDIOGRAPHY
• Systolic function of the right and left
ventricle decreases due to DCM
• Dilatation of all heart chambers
• Excentric LVH
• Global hypokinetic
• Severe Mitral regurgitation, Low Tricuspid
regurgitation, Moderate Pulmonal
regurgitation,
• Moderate Pulmonal hypertension
• Left ventricular diastolic dysfunction grade
III
 PEMERIKSAAN NILAI NILAI RUJUKAN UNIT
WBC 7.8 4.00-10.00 10˄3/ul
RBC 5.25 4.00-6.00 10˄6/ul
Hb 16.1 12.0-16.0 gr/dl
Plt 112 150-400 10˄3/ul
PT 22.7 10-14 Detik
APTT 30.6 22.0-33.0 Detik
INR 1.98 --
GDS 90 140 mg/dl
Ureum 113 10-50 mg/dl
Creatinin 1.28 L(<1.3) P(<1.1) mg/dl
SGOT 578 <38 U/L
SGPT 492 <41 U/L
CK 963.00 L(<190), P (<167) U/L
CKMB 49.0 <25 U/L
Troponin I 0.65 <0.01 ng/ml
Natrium 129 136-145 mmol/l
Kalium 4.8 3.5-5.1 mmol/l
pH 7.539 7.35-7.45

pCO2 32.0 mmHg

SO2 96.8 %

PO2 77.9 80.0-100.0 mmHg

HCO3 27.6 22-26 mmol/l

ctO2 23.4 Vol%

ctCO2 28.5 mmol/l

BE 4.8 -2 sd +2 mmol/l
 Chf nyha iII ec.
MODERATE
ALCOHOLIC
CARDIOMYOPATHY
 Bed rest
 Oxygen 3-4 lpm via nasal canule
 IVFD NaCl 0.9% 500 cc/24 hr

 Diuretic
Furosemid 2 amp/8 hr/iv

 ACE Inhibitor
Captopril 12.5mg/8hr/oral

 Expectorant
Ambroxol 20mg/8hr/oral
DISCUSSION
HEART FAILURE
Heart is no longer able to pump an
adequate supply of blood in relation to the
venous return and in relation to the
metabolic needs of the body tissues at the
particular moment

The state in which abnormal

circulatory congestion occurs as
the result of heart failure.
 Myocard Myocard Mechanical
Disease Dysfunction
Pressure overloaded
CAD (Stenosis Aortae, Hypertension,
Coartatio Aortae)
Volume Overloaded
Cardiomyopathy
(Mitral/Aortae Regurgitation,
Congenital Heart Disease,
Hipertransfusion)
Iatrogenic
Miocard Filling Inhibitating
(Cardiac Tamponade, Pericarditis)
Miocarditis
 The Framingham criteria for CHF
CHF considered present if 2 major or 1 major & 2 minor
Major Criteria Minor Criteria
• Paroxysmal Nocturnal • Extremity edema
Dyspnea • Nocturnal cough
• Cardiomegaly • Decreased vital pulmonary
• Gallop S3 capacity (1/3 of maximal)
• Hepatojugular reflux • Hepatomegaly
• Increased of JVP • Pleural effusion
• Rales or ronchi • Tachycardia (≥ 120bpm)
• Acute pulmonary edema • Dyspnea d’effort
• Prolonged circulation time(>
25 sec)
• Weigh loss ≥ 4,5 kg in 5 days
in
response to treatment of
CHF
*
*
 Non-
Farmakologi
Farmakologi
 Medical Therapy
*ACE-Inhibitor
*Digitalis
*Diuretic
*Anti-arrhytmia
*Digoxin
*Anti-coagulant
*Antibiotic
 Surgical intervention
• Symptomatic with severe MR
• Asymptomatic with severe MR and preserved LV
function
• Asymptomatic with severe MR and Left ventricle end
systolic diameter (LVESD)