CASE REPORT
CONGESTIVE HEART
FAILURE
C11115041 Alma Aulia Rivanti
Supervisor:
dr Akhtar Fajar Muzakkir, Sp.JP, FIHA
Name : Mr. YK
Age : 71 yo
Gender : Male
Occupation : Retired Military
Religion : Catholic
Address :TNI AU Purn. Comp.
Admitted on : February 8th, 2019
MR : 872763
Chief Complaint
Shortness of breath
Recent Disease History
Suddenly feeling shortness of breath since 3 hours ago before admitted to
the hospital. It was aggravated by the change of position especially in
supine position, and didn't affected by activity or weather. The patient's
condition was relieved by tilted to the side. There was a history of
coughing, and there were no history chest pain, fever, nausea and
vomiting. Normal defecation and micturition
Past Disease History
History of admitted to hospital for 3 times with the same complaint
History of hypertension was denied
History of diabetes mellitus was unknown
History of dyslipidemia was unknown
Family History
History of family with cardiovascular disease, diabetes mellitus, and
hypertension were unknown
Habitual History
There is no history of smoking
Sometimes drank alcohol
Unmodifiable
Age
Modifiable
Drinking alcohol, Obese
General Status
Moderately ill / adequate nutrition / composmentis
Weight : 82 kg
Height : 167 cm
BMI : 29.4 kg/m2 (Obese 1)
Vital Sign
BP : 130/90 mmHg
HR : 100 bpm
RR : 26 bpm
Temp : 36.7º C
Head and Neck Examination
Eyes : anemic (-), icteric (-)
Lips : cyanosis (-)
Neck : JVP R+4 cm H2O, there is no lymphadenopathy and thyroid
enlargement
Thorax Examination
Inspection : Symmetric
Palpation : Tumor mass (-), tenderness (-)
Percussion : Sonor left and right, lung hepar border in right ICS 6
Auscultation : Vesicular, additional sound rhonchi basal bilateral minimal,
wheezing -/-
Heart Examination
Inspection : Ictus cordis (-)
Palpation : Ictus cordis palpable
Percussion : Right border in right ICS 4 linea midclavicularis, left border in
ICS 5 linea axillary anterior, upper border in ICS 2
Auscultation : Reguler SI/SII, murmur (-)
Abdomen Examination
Inspection : Follow breathing movement, ascites (-)
Auscultation : Normal peristaltic (+)
Palpation : Tumor mass (-), tenderness (-), lien not palpable, hepar
palpable
Percussion : Tympany (+), shifting dullness (-)
Extremity Examination
Pretibial oedema (+)
EXAMINATION RESULT REFERENCE UNIT
PT 11.2 10-14 seconds
INR 1.08 -
APTT 23 22-30 seconds
Glucose GDS 69 140 mg/dl
Ureum 18 10-50 mg/dl
Creatinin 1.41 L (<1.3); P (<1.1) mg/dl
SGOT 79 <38 U/L
SGPT 46 <41 U/L
Albumin 2.9 3.5 – 5.0 gr/dl
Natrium 135 136 – 145 mmol/l
Kalium 2 3.5 – 5.1 mmol/l
Chloride 94 97 – 111 mmol/l
WBC 7.06 x 103/ uL 4 – 10
RBC 3.75 x 106/ uL 4–6
HGB 12.1 g/dL 12 – 16
PLT 195 x 103/uL 150 – 400
ECG (08/02/19)
Rhythm : Supraventricular rhythm
Heart Rate : 100 bpm
Regularity : Irregular
Axis : Normoaxis
P wave : None
PR interval : Can't be observed
QRS complex : Narrow, QRS interval 0.08 sec
ST segment : Normal
T wave : Normal (2 mm)
Conclusion : Atrial fibrillation normoventricular response, heart rate 100 bpm irregular
Echocardiography (09/02/19)
• Normal left ventricle systolic function, EF 63.3%
• Concentric left ventricle hypertrophy
• Mild left ventricle diastolic dysfunction
X-Ray Thorax (09/02/19)
• Vascular suprahilar dilatation both lungs
• Thickened right pleura
• Cor : enlarge, aorta dilatation
• Hidden sinus and left diaphragm
• Intact bones
• Surrounding soft tissue normal
Conclusion : Cardiomegaly with signs of lungs oedema, minimal
effusion of bilateral pleura
Congestive Heart Failure NYHA IV (Grade C)
Hypertensive Heart Disease
Suspect Non Hemorrhagic Stroke
NaCl 0.9% 500 cc/24 hours/drips
Lansoprazole 30 mg/24 hours/intravenous
Anti coagulant: Aspilet 80 mg/24 hours
B-blocker: Concor 2,5 mg/24 hours/oral
KCl 50 mcg/24 hours/syringe pump
N-ace 200 mg/8 hours/oral
Citicoline (if SBP ≥110 mmHg) 500 mg/24 hours/intravenous
Mecobalamin 500 mg/ 4 jam/intravena
DISCUSSION
Congestive Heart Failure
Heart failure is the disability of heart to maintain
cardiac output in fulfilling body metabolism.
Decreases in cardiac output can lead to decrease of
effective blood volume
1. Myocard Infarct or Coronary Artery Disease
2. Dilated Cardiomyopaty
3. Hypertension
4. Valvular Heart Disease
5. Arrhythmia
6. Congenital Heart Disease
7. Kidney failure
8. Hyperthyroidism or Hypothyroidsm
Pathophysiology
Hypertension
Congestive Heart
Afterload Failure
Left Ventricle
vascular congestive
Hypertrophy
Impaired Diastolic
Ventricle stiffness
filling
Underlying etiology
Cardiac output
Compensation
mechanism
Sympathetic nerve RAA system
Contractility Preload
Cardiac output
Uncompensated
Heart failure
Classification according to Heart Structural Classification according to Functional Capacity
Abnormality (AHA) (NYHA)
Class I
Grade A
No limitation of physical activity. Ordinary physical
At high risk for HF but without structural heart disease
activity does not cause fatigue, palpitation, or shortness
or symptoms of HF
of breath
Class II
Grade B
Slight limitation of physical activity. Comfortable at rest
There is a structural heart disorder but no symptoms at
but ordinary physical activity cause fatigue, palpitation,
this stage
or shortness of breath
Grade C Class III
Previous or current symptoms of heart failure in theMarked limitation of physical activity. Comfortable at
context of an underlying structural heart problem, butrest, but less than ordinary activity causes fatigue,
managed with medical treatment palpitation. or shortness of breath
Class IV
Grade D Unable to carry on any physical activity without any
Refractory HF requiring specialized intervention complaint. There is symptoms at rest. Increase complaint
when doing activity
Etiologi yang mendasari
Curah jantung
Mekanisme
kompensasi
Saraf simpatis Sistem RAA
Kontraktilitas Preload
Curah jantung
tidak terkompensasi
Gagal jantung
• Paroxysmal nocturnal dyspnea • Extremity oedema
• Neck vein distention • Coughing at night
• Elevated JVP • Dyspneu on Effort
• Ronchi • Hepatomegaly
• Cardiomegaly • Pleural effusion
• Acute lung oedema • Decrease in vital capacity 1/3 than
• Gallop S3 normal
• Positive hepatojugular reflex • Tachycardia (>120 bpm)
Major Minor
Mayor or Minor
Weight loss ≥ 4,5 kg in 5 days of
treatment
Diuretic Ace-Inhibitor
•Decrease Preload •Decrease afterload
•Prevents remodelling
•Hypertension treatment
B-blocker
•Decrease Heart Rate
Thank You
