Case Report

A woman 70 years old came to

hospital with severe shortness of
breath since 2 hours ago
By :
Al Hafizh Utama, S.Ked
Niken Kasati, S.Ked

Supervisor: dr. H. Syamsu Indra, SpPD-KKV, FINASIM, MARS

Introduction
Heart failure is often referred to as congestive heart failure (CHF) is the
inability of the heart to pump blood in sufficient quantities to meet the
networking needs of the nutrients and oxygen

Based on data from Medicare in the United States, heart failure is the leading
cause of hospitalization of the most widely in hospitals. The prognosis of heart
failure too bad with a mortality rate of 30-50 percent a year in patients with
severe symptoms. The high incidence and mortality in congestive heart failure
demonstrated that this case requires further attention. That is why this case
needs to be removed for study.
Identification
Name : Ny.WBM
No. Reg : 912763
Age : 70 years
Gender : Female
Address : Desa Batu Mas, Tanjung Raja, Ogan Ilir
Occupation : Housewife
Religion : Islam
Chief Complain:
Severe shortness of breath since 2 hours ago

Additional Complain:
Swollen Legs since 2 months ago

9/2/2017
Story of Disease
2 months ago
Os complained of shortness of breath when the activity as to the bathroom or
prayer. Os difficulty sleeping at night because of shortness. Os sleep with 3 pillows
arranged. Wheezing (-), chest pain, cough (+), no phlegm, do not bleed, and cough
especially at night. Nausea (-), regurgitate (-), heartburn (-), swollen legs (+), swollen
in the abdomen (-), fever (-), urinate normal, and defecation normal. Os dont seek
treatment.

2 hours ago
Os complained of severe shortness of breath. Tightness is not reduced at the break.
Weather tightness is not influence by dust and emotions. Wheezing (-), chest pain (-),
cough especially at night (+), nausea (-), vomiting (-), heartburn (-), swollen legs (+),
swollen abdomen (+), fever (-), Urinate nomal, and defecation normal. Os went to the
RSMH Palembang.

9/2/2017
 History of Disease

History of the disease with the same complaint denied.

A history of high blood

History of diabetes denied

Asthma denied

History of kidney disease is undeniable

9/2/2017
 History of Disease in Family

History of the disease with the same complaint denied.

A history of high blood denied

History of diabetes denied

Asthma denied

History of kidney disease is undeniable

9/2/2017
Physical Examination
General : Moderate pain
Awareness : Compos mentis
Blood Pressure : 140/100 mmHg
Pulse Rate : 96 x / m regular, content, and sufficient normal
Temperature : 36.8 C
Respiration Rate : 34 x / m, regular, type thorakoabdominal
Weight : 56 kg
Height : 156 cm
BMI : 23.3 normal impression

9/2/2017
Specific Examination
Head : Normochepali, anemis conjunctiva (-), and icteric sclera (-)

Neck : JVP (5+2) cmH2O, enlarged lymph node (-)

Chest : Normal thoracic shape. There is no barrel chest, retraction

of the thoracic wall (+), venektasi (-), and spider nevi (-)

Lungs
Inspection : Static, dynamic symmetrical right and left
Palpation : Stemfremitus right = left
Percussion : Sonor in both lung fields
Auscultation : Vesicular (+) normal, smooth wet ronkhi (+) in both lung
bases, and wheezing (-)
 Cor
Inspection : Ictus cordis was not visible
Palpation : Ictus cordis was not palpated
Percussion : The upper limit heart ICS II, 1 finger right lateral linea,
parasternalis dextra, and left anterior axillary line.
Auscultation : HR: 96x / m, HS I and II normal, murmur (+) systolic grade 4/6,
the pulmonary valve, gallops (-)

Abdomen
Inspection : Convex
Palpation : Liver palpable 2 finger widths below the arcus costae, Lien is
difficult to assess, undulation (-)
Percussion : Shifting dullness (+)
Auscultation : Noisy intestine (+) Normal

Extremity : Swolling leg (+)

9/2/2017
Laboratory Result
Uric Acid : normal <8,4 15
Na : normal 135-155 128
K: normal 3,5-5,5 3,7
Kolesterol : normal <200 280
HDL : normal >65 40
LDL : normal <100 225
Trigliserid : normal <150 280

9/2/2017
ECG

Interpretation:
OMI Lateral, Ekstensif anterior, RVH
Rontgen
Interpretation:
AP photo
Conditions good photo
= Left-right symmetric
Trachea in the middle
Good bones
Ribs is not widened
CTR> 50%
Costophrenicus angle right and
left blunt.
Lung parenchyma: normal
vascular markings.

Conclusion:
Cardiomegaly (boot shaped) and
pleura bilateral effusion.
Diagnosis
CHF NYHA IV e.c HHD + hypertension stage
I + pleura bilateral effusion + uricemia + dyslipidemia

9/2/2017
Differential Diagnosis
CHF NYHA IV e.c ASHD + hypertension stage I + pleura bilateral
effusion + uricemia + dyslipidemia

CHF NYHA IV e.c RHD + hypertension stage I + pleura bilateral

effusion + uricemia + dyslipidemia
 Treatment
Non Farmacology Farmacology
- O2 3L/m - IVFD RL gtt X/menit mikro
- Bedrest - Furosemid injection 1 x 20 mg (iv)
- Education - Captopril 2 x 12.5 mg
- Laxadine syr 3 x 1 c
- Spironolkton 1 x 25 mg
- Simvastatin 1 x 10 mg
 Framingham Score
Major criteria: Minor criteria

Paroxysmal nocturnal dyspnea (+) Legs edema (+)

Distended neck veins (+)
Ronkhi (+)
Cardiomegaly (+)
Acute pulmonary edema (+)
Gallop S3 (-)
Elevation of the jugular venous
pressure (+)
Hepatojugular reflux (-)
Nighttime cough (+)
Dispneu d'effort (+)
Hepatomegaly (+)
Pleural effusion (-)
Decline in 1/3 of normal vital capacity
(-)
Tachycardia (> 120 x / min) (-)

2 Criteria 1 Criteria Major and Minor has been fulfilled.

9/2/2017
Prognosis

Quo ad vitam: dubia

Quo ad functionam: dubia ad malam
Quo ad sanationam: dubia ad malam
 Case Analysis

Heart failure is a pathophysiological state in the form of cardiac dysfunction so that

the heart can not pump blood to meet the metabolic needs of the network.

Heart failure is divided into left heart failure, right heart failure and congestive heart
failure, which is the combined left and right heart failure.

Left heart failure is characterized by dispneu d'effort, fatigue, orthopnea, paroxysmal

nocturnal dyspnea, cough, enlarged heart, clattering rhythm, sound derapS3 and S4,
Cheyne Stokes breathing, tachycardia, crackles and pulmonary venous congestion.

Right heart failure is characterized by fatigue, pitting edema, ascites, increased

jugular venous pressure, hepatomegaly, enlargement of the right heart, the right
atrium clattering rhythm, murmurs and sounds P2 hardened, while the
manifestations of congestive heart failure symptoms occur a combination of both.

9/2/2017
 The diagnosis of congestive heart failure is established: there are 2 major criteria or
1 major criterion and 2 minor criteria (Framingham criteria) coupled with the
investigation.

Major criteria:
paroxysmal nocturnal dyspnoea or orthopneu, elevated jugular venous pressure,
crackles wet is not loud, cardiomegaly, acute pulmonary edema, S3 clattering
rhythm, increased venous> 16 cm H2O and reflux hepatojugular.

Minor criteria: ankle edema, cough at night, dispneu d'effort, hepatomegaly, pleural
effusion, vital kapisitas reduced to 1/3 maximum and tachycardia (> 120x / min).

The results of X-ray examinations can lead to cardiomegaly with increased

bronkovaskuler markings.

9/2/2017
 In these patients, the results obtained their history of shortness of breath, tightness is
affected by the activity, patients also often wake up at night because of tightness, but
it is also more convenient if the patient is in a sitting position. The absence of other
complaints such as headache, nausea, vomiting, swelling of the eyelids support that
tightness experienced by the patient associated with heart instead of other organs. In
addition, patients also complain of enlarged abdomen.

From the results of physical examination found blood pressure of 140/80 mmHg.
found also an increased jugular venous pressure, crackles smooth wet (RBH) in both
lung bases, widening, heart border, and the presence of ascites.

9/2/2017
 Based on the history and physical examination of the above, it can be concluded that
in these patients can be diagnosis of congestive heart failure, because the
Framingham criteria are met. other than that based on JNC 8 os suffering from
hypertension stage 1

The main treatment is given 1x 20 mg of furosemide, a diuretic administration aims

to reduce excess fluid in the lungs and ascites contained in these patients. and to
reduce the initial load of the heart without reducing cardiac output.

Moreover given soundly 2 x 12.5 mg captopril for the management of hypertension.

9/2/2017
9/2/2017