CASE REPORT CHF

Presented by: Nisa Uswatun Karimah Lydia Octasari Advisor: dr. Erwin Sukandi, Sp.PD

IDENTIFICATION
Name : Mrs. Rn Age : 27 years Sex : female Address : Ds. Rejodadi Kab. Banyuasin Marital status: married Occupation : house wife Religion : moslem Admitted to hospital : November 5, 2008

ANAMNESIS

CHIEF COMPLAIN
Shortness of breath again so heavy since 1 week before admission

HISTORY OF ILLNESS
3 months before admission: shortness of breath, depended on position and activity. She felt shortness of breath when go to toilet. She felt better if she sat or slept with taking 2-3 pillows. Shortness of breath wasnt depended on weather & emotion, not followed by mengi voice. Wake up midnight caused shortness of breath (+), heart palpitation (+). Chest pain (-), cough (-), fever (-), sweating at night (-).

Swelling in both of lower extremity (+), swelling in upper eye lids (-). Being yellowish in eyes and skin (-). Epigastrium pain (+), nausea (+) but no vomit. No problem in urination and defecation. She went to RSMH and was hospitalized for 10 days until she got well.

1 month before admission

She complained of having shortness of breath again, depend on position & activity. She felt shortness of breath after walking 5 m, being better if she took a rest. It wasnt depended on weather or emotion, not followed by mengi voice. Slept with 3-4 pillows. Wake up in midnight caused by shortness of breath (+). Heart palpitation (+). Chest pain (-), cough (-), fever (-), sweating at night (-). Swelling in both two lower extremity (+).

Swelling in upper eye lids (-). Being

yellowish in eyes and skin (-). Being

yellowish in eyes and skin (-). Epigastrium

pain (+), nausea (+) but no vomit. No

problem in urination and defecation. She

was taken to RS Siti Khodijah and

hospitalized for 25 days until she got well.

1 week before admission

She complained of having shortness of breath again so heavy, depended on position & activity. She felt better if she sat, but she couldnt walk anymore. It wasnt depended on weather & emotion. Not followed by mengi voice. Slept with taking 4-5 pillows. Woke up in midnight caused by shortness of breath (+). Heart palpitation (+). Chest pain (-), fever (-), sweating at night (-).

Swelling in both of lower extremity (-),

swelling in upper eye lids (-). Being yellowish

in eyes and skin (-). Epigastrium pain (+),

nausea (+) but no vomit. No problem in

urination and defecation. She was taken to

RSMH again for these complains.

HISTORIES OF PAST ILLNESS

H/ of heart disease since 14 years ago, hospitalized min. once in a year H/ of joint and bone pain (+) since 10 years old H/ of hypertension was denied H/ of DM was denied H/ of kidney disease was denied H/ asthma was denied H/ being blue when baby was denied H/ gastric pain since 10 years ago

HISTORIES OF FAMILY DISEASE

H/ of heart disease (+) in her mother H/ of hypertension (+) in her mother, too

PHYSICAL EXAMINATION

GENERAL EXAMINATION
General condition : sick Sickness condition : severe sickness Consciousness : compos mentis Blood pressure : 90/60 mmHg Pulse rate : 100 x/min, irregular Respiration rate : 40 x/min Temp. : 36,90C Dehydration : (-) Nutrition : weight = 35 kg, height = 155 cm impression : undernutrition

SPESIFIC EXAMINATION
Skin Skin color is puce, normal pigmentation, efloresence (-), icteric (-), cyanotic palm & palmar (-), scar (-), hyperhydrosis (-), normal hair growth, good turgor, wet/dry in palpitation (-), subcutaneous nodule (-). Lymph gland no enlargement of the lymph nodes on submandibular, neck, axillaries, & inguinal.

 Head oval, symmetrical, puffy face (-), deformity (-), malar rash (-), alopecia (-) Eyes exophtalmus & endophtalmus (-), edematous superior palpebra (-), pale of conjunctiva palpebra (-), icteric sclera (-) Nose epistaxis (-), normal nasal septum and mucous layer

 Ears good hearing, normal both of meatus acusticus externus Mouth rhagaden of lips (-), stomatitis (-), papil atrophy (-), gum bleeding (-), fetor oris (-) Neck thyroid gland not palpabled, thyroid bruit (-), JVP (5+2) cmH2O, hypertrophy of musculus sternocleidomastoideus (-), stiffness (-)

 Thorax normal shape, extended intercostal section (-), retraction (-), venectasis (-), spider naevi (-) Lung I : symmetrical of static & dynamic right = left P: right stemfremitus is weaker on base of lung P: dull in right lung started at ICS IV, sonor on the left lung A: ves (+) weaker on base of right lung, soft wet rales on all lung, wheezing (-)

 Cor I: ictus cordis was seen in ICS VI P: ictus cordis was palpable in ICS VI, thrill (+) P: upper boundary of cor is at ICS III, left boundary is at LAA sinistra, right boundary cant be evaluated A: HR = 110 x/min, irregular, murmur (+) systolic & diastolic on all the valves, grade IV, punctum maximum is at mitral valve, gallop (-)

 Abdomen I: flat, venectation (-) P: pain on epigastrium region, spleen is unpalpable, liver is palpable 7 fingers under arcus costa, sharp edge, elastic consistency, flat surface, palpable pain (+) P: tympany, shifting dullness (-) A: bowel sound (+) normal External genitalia not examined

 Upper extremity pain on join (+), pale on finger (-), erythema of palm (-), pitting edema (-), clubbing finger (-), tremor (-), normal physiological reflex Lower extremity pain on join (+), pale on finger (-), erythema of palm (-), pitting edema (-), clubbing finger (-), tremor (-), normal physiological reflex

ADDITIONAL EXAMINATION

ELECTROCARDIOGRAPHY (Nov 5, 2008)

AF, normal axis, HR = 110-140 x/min, P wave cant be evaluated, QRS complex 0.04 seconds, R/S V1 < 1, S V1 + R V1/V5/V6 > 35, S persistent (+) in V5-V6 Impression: rapid ventricular respond AF + LVH

LABORATORY FINDINGS (Nov 5, 2008)

Blood analysis Hemoglobin : 10.8 g/dl Hematocrite : 32% Leucocyte : 6500/mm3

(14-18 g/dl) (40-48%) (500010000/mm3) ESR : 30 mm/hr (< 10 mm/hr) Thrombocyte : 291,000/mm3 (200,000500,000//mm3) Diff count : 0/5/2/77/12/4

BSS Cholesterol total HDL-cholesterol LDL-cholesterol Triglyceride Uric acid Ureum Creatinin Total protein Albumin Globulin

: 105 mg/dl : 155 mg/dl : 45 mg/dl : 91 mg/dl : 96 mg/dl : 4.5 mg/dl : 18 mg/dl : 0.7 mg/dl : 6.6 g/dl : 3.1 g/dl : 3.5 g/dl

(< 200) (> 55) (< 130) (< 150) (1.6-6.0) (15-39) (0.9-1.3) (6-7.8) (3.5-5)

Total bilirubin Direct bilirubin Indirect bilirubin SGOT SGPT LDH Sodium Potassium

: 1.8 mg/dl : 1.22 mg/dl : 0.58 mg/dl : 35 U/l : 39 U/l : 266 U/l : 135 mmol/l : 5.0 mmol/l

(0.1-1) (< 0.25) (< 0.75) (< 40) (< 41) (160-320) (135-155) (3.5-5.5)

Urinalysis Epithelial cell Leucocyte Erythrocyte Cylinder Crystal

: (+) : 0-1/LPB : 0-3/LPB : (-) : (-)

(0-5/LPB) (0-1/LPB) (negative) (negative)

CHEST X-RAY (Nov 5, 2008)

Condition of the photo was good Right and left are equal Trachea was in the middle No extended intercostal section Condition of the bone was good, no fracture CTR was difficult to seen Right costophrenicus angle was difficult to evaluated, left costophrenicus was keen Right diaphragm is at ICS II Parenchyme cephalization (+) Impression: subdiaphragm process + cardiomegaly + acute lung edema

ECHOCARDIOGRAPHY
EDO : 5.47 ESO : 4.06 PW : 0.65 IVS : 0.74 LA : 13.3 AO : 3.04 EF : 50.3 FS : 25.8 LA/AO : 4.37 LV dilatation, LA dilatation LVH (-) LV EF 50% MS severe, MVA = 1.76, MPG 13-19 MR severe AR moderate AS mild-moderate TR moderate

~ MVD e.c. RHD

RESUME
A woman initialed Mrs. Rn, 27 years, admitted to hospital in November 5, 2008 with shortness of breath again so heavy since 1 week before admission as the chief complain. 3 months before admission, she complained of having shortness of breath, depended on position & activity after going to toilet. She felt better if she took a rest and slept with 2-3 pillows. Wake up in midnight caused by shortness of breath (+), heart palpitation (+). Swelling in both of lower extremity (+), epigastric pain (+), nausea (+). She went to RSMH & hospitalized.

1 month before admission, she complained having shortness of breath again, depended on position & activity after walking 5 m. She felt better if she took a rest or slept with 3-4 pillows. It was not depended on weather & emotion, not followed by mengi voice. Wake up in midnight caused by shortness of breath (+), heart palpitation (+). Swelling in both of lower extremity (+), epigastric pain (+), nausea (+). She went to RS Siti Khodijah and hospitalized for 25 days.

1 week before admission, she complained having shortness of breath again, depended on position & activity. She felt better if she took a rest or slept with 4-5 pillows. She couldnt walk anymore. It was not depended on weather & emotion, not followed by mengi voice. Wake up in midnight caused by shortness of breath (+), heart palpitation (+), epigastric pain (+), nausea (+). She went to RSMH again for these complains. She had history of heart disease since 14 years ago, hospitalized minimal once in a year, and history of pain in joint & bone since 10 years old. History of heart disease & hypertension (+) in her mother.

From physical examination, the general condition was severe sickness, consciousness was compos mentis. BP was 90/60 mmHg, pulse rate 100 x/min, irregular, RR = 40x/times, temp 36.90C, RBW = 70,7% with undernutrition impressive, JVP (5+2) cmH2O. In anterior & posterior of the lung, there was soft wet rales on both of legt and right lung, while in cor, ictus cordis was seen and palpable in ICS VI, thrill (+), upper boundary is at ICS III, left boundary is at LAA sinistra, & right boundary cant be evaluated, HR = 110 x/min, irregular, murmur (+) systolic & diastolic on all the mitral valves, gallop (-). While abdomen examination, liver is palpable 7 fingers under arcus costa.

FRAMINGHAM SCORE
Major criteria : Paroxysmal nocturnal dyspnea Distention of neck vein Rales on pulmo Cardiomegaly Acute pulmonary edema Gallop S3 Increased of JVP Hepatojugular reflux (+) (-) (+) (+) (+) (-) (+) (+)

Minor criteria : Extremity edema Cough in night time Dispnea deffort Hepatomegaly Pleural effusion Decreased of vital capacity Tachycardia (> 120 x/min)

(-) (-) (+) (+) (-) (-) (-)

WORKING DIAGNOSIS
CHF e.c. MVD e.c. RHD

DIFFERENTIAL DIAGNOSIS CHF e.c. MI/MS e.c. RHD CHF e.c. congenital valve abnormality

TREATMENTS
Nonpharmacology : O2 3 l/min Bedrest (half-sit position) Cor diet III Pharmacology : IVFD D5 gtt X/min (microdrip) Furosemide amp 1x1 Spironolactone tab 1x25 mg Digoxin 1x0.25 mg Laxadin syr 3x1 c Omeprazole tab 1x20 mg

PLANNING
Repeat echocardiography Electrolyte examination

PROGNOSIS
Quo ad vitam Quo ad functionam : dubia et malam : dubia et malam

TERIMA KASIH