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A 65 y/o man with Congestive
Heart FailureAngelia Elisabeth Mambu030.09.019
MEDICAL FACULTY OF TRISAKTI UNIVERSITY
RSUD KARAWANG
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Identity Mr. NurhadiName
62 y/oAge
MaleSex Jl.Citarum no 29 Tunggakjati, Karawang
BaratAddress
-Ocupation
MoeslimReligion
MarriedMarital Status
High SchoolEducation
SundaneseEthnic
14th
June 2013Admitted
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Shortness of breath since 2
days before hopitalizedChief
Complain
Fatigue
Swelling in both feet Cough Lack of sleep
AdditionalComplain
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History of Present IllnessThe patient came to Emergency Unit of Karawang
Hospital with complaint of shortness of breath since 3
months before hospitalized. The symptom felt worseningand appeared when he is in rush and during her normalactivities such as sweeping . To relief the symptom he isusing 2 - 3 pillows when sleeping. She always suddenlywoken up when she is sleeping because of breathlessness.
He also complains about his swelling feet whichgetting worse from day to day. She denied having a chest
pain, fever, nausea and vomit but suffered a bit of coughand exhausted.
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History of Past illness
Hypertension(+) DiabetesMelitus (+)
Asthma (-)
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History of Family Illness
History of FamilyIllness
Same disease (-) Hypertension (+) Diabetes Melitus
(+) Asthma (-)
Personal and SosialHistory
Smoking (-)
Alcohol (-)
Exercise regularly (-)
ConsumeHypertension drugsand DM drugsregularly
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Physical Examination
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General Condition
General
appearance Moderately ill
Consciousness
Compos mentis
Blood
Preasure150/90
Heart Rate
96 x/min
RespirationRate
24 x/min
Temperature36oC
VitalSign
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Normochepaly, black hair,good distributionHead
Anemic conjungtiva -/- Icteric sclera -/-Eyes Thyroid gland & lymph nodes
enlargement are not palpable JVP : (5+4) cmH2O
Neck
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Thorax - HeartInspection
Ictus cordis is visible
Palpation
Ictus cordis is palpable at 6th ICS 3 cm lateral LMCS
Percussion Enlargement of the heart, shifting left border of the heart
Auscultation
Regular I II heart sound. No murmur and gallop
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Thorax - Lung
SymmetricalInspection
Equal vocal resonancePalpation
Sonor in both lungsPercussion
Vesicular, Ronchi (+/+) at baseboth lungs, Wheezing (-/-)Auscultation
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Abdomen brown skin, symetrical
Inspection
Bowel sound (+)
Auscultation
Turgor normal, muscular defense (-), mass(-), hepar and lien enlargement (-)Palpation
Tympanic, no pain present on abdominalpecussion, Shifting dullness (-)Percussion
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Ekstremity
+ +
+ +
Warm Acrals Edema
- -
+ +
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Laboratory test (14th June 2013)Result Normal
Hb 12,3 12 17 g%
Leukosit 7.990 5000
10000Trombosit 193.000 150rb 450rb
Hematocrit 35 37 48 %
GDS 45 80 140 mg/dl
Ureum 48,6 10 45 mg/dl
Creatinin 1,52 0,4 1,5 mg/dl
Na 136 134 145 mmol/L
K 4,6 3,5 5,6 mmol/L
Cl 106 100 110 mmol/L
CK-MB 22 < 24 U/l
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Laboratory test
16th June2013
GDS = 248
18th June2013
GDS = 190
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ECG old MCI anterior
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Thorax foto AP
CTR > 50%
Enlargement of Left Ventricle(LVH)
Enlargement of Left Atrium(LAH)
Right costophrenicus angle isblunt
Pleura efusion dextra
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Echocardiography Dimensi ruang jantung : LA
dilated
LVH (+) konsentrik, EPSS 0,92 cm
Kontraktilitas LV baik, EF 55% Kontraktilitas RV baik, TAPSE 2
cm
Analisa segmental : hipokinetikringan inferior wall
Katup: Ao 3 cupis, kalsifikasi (+), AR
trivial, MR mild, TR mild, PR mild
Doppler : E/A > 1, Ao V max 1,1m/s. mPaP 20 mmHg
KESIMPULAN
CAD, LA dilated
Fungsi sistolik LV baik, EF55%
LVH (+) konsentrik
AR trivial, MR mild, TR mild,PR mild
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Working Diagnosis
CHF NYHA II et causa CADand
Hipoglycemia in Diabetes Melitus tipe II
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Diferential Diagnosis
CHF NYHA II e.c HHD
CHF NYHA II e.c Cardiomiopathy
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Treatment
IVFD Dextrose 10 %
Furosemide 2 x 1
Tromboaspilet 1 x 1
ISDN 5mg 3 x 1
CPG 1 x 1
Adalat oros 1 x 1 Irbedox 1 x 1
Bisoprolol 1 x
Novomix 12 - 0 - 12
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Prognosis
Ad vitam
AdSanationam
AdFungsionam
Dubia ad
bonam Dubia ad
malam
Dubia admalam
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CHF
Congestive heart failure (CHF) is a condition inwhich the heart's function as a pump is
inadequate to deliver oxygen rich blood to thebody.
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Etiology
The most common causes of congestive heartfailure are:
coronary artery disease
high blood pressure (hypertension)
longstanding alcohol abuse
disorders of the heart valves unknown (idiopathic) causes, such as after
recovery from myocarditis
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Symptoms Cough Fatigue, weakness, faintness
Loss of appetite Need to urinate at night palpitations Shortness of breath when you are active or after you
lie down Swollen (enlarged) liver or abdomen Swollen feet and ankles Waking up from sleep after a couple of hours due to
shortness of breath
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Diagnosed
Mayor
Paroxysmal nocturnal dyspnea Neck vein distention Rales Radiographic cardiomegaly Acute pulmonary edema
S3 gallop Increased Jugularis Vena
Pressure Hepatojugular reflux
Minor
Bilateral ankle edema Nocturnal cough Dyspnea on ordinary exertion Hepatomegaly Pleural effusion
Decrease in vital capacity byone third from maximumrecorded
Tachycardia (heart rate>120beats/min.)
Framingham Criteria for Congestive HeartFailure
.
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Framingham Criteria for CongestiveHeart Failure
2 major1 major2 minor
Diagnosis of CHF requires the simultaneouspresence of at least
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NYHA Classification - The Stages of
Heart FailureNo limitation of physical activity. Ordinary physical activity
does not cause undue fatigue, palpitation, or dyspnea(shortness of breath).Class I
Slight limitation of physical activity. Comfortable at rest,but ordinary physical activity results in fatigue, palpitation,or dyspnea.Class II
Marked limitation of physical activity. Comfortable at rest,but less than ordinary activity causes fatigue, palpitation,or dyspnea.
Class IIIUnable to carry out any physical activity without
discomfort. Symptoms of cardiac insufficiency at rest. Ifany physical activity is undertaken, discomfort isincreased.
Class IV
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Treatment
Diet Exercise
NonFarmachologist
Ace inhibitor Beta blocker Diuretic
Digoxyn
Farmachologist