CONGESTIVE HEART FAILURE

CASE REPORT SESSION

To fulfill the case report assignment

Zulpah Ayu P
Fila Indina K P
Milana
Syarifah Helviza
Yannuar M
Gilang C P

FACULTY OF MEDICINE
GENERAL ACHMAD YANI UNIVERSITY
CIMAHI
2019
General Information:
Patient Name : Mrs. Mimi Karwati
Ward : Ceremai, Room 3
Medical Record Number : 576595
Gender : Female
Age : 70 Years Old
Religion : Islam
Occupation : No Occupation-Retired
Address : Kol Masturi Street Number 28 Cipageran Cimahi
Utara
Date of Entry : 18 February 2019
Date of Examination : 19 February 2019

ANAMNESIS
Chief Complaint:
Breathlessness

Auto-Anamnesis:
Present Illness:
An 70-years-old women presents to the Emergency Room (ER) with breathlessness
that was endured for the past 2 weeks. She reported that 6 hours ago. Breathlessnes
is severely especially when she physical activity example walk 2-3 meters from the
place, walk to bathroom. short of breath and become better when she take a rest or
sitting. The patient also complained of breathlessness that occurred during the night
which made it hard to sleep. When resting, she usually used 2 pillows because it
eased her current symptoms to a certain extent.The patient had an occasional cough
accompanied with leg swelling in 1 week ago. Swelling only at leg and doesn’t
appear at face and eye lid.
Previous Medical History:
She stated that this condition is for the first time. She also had previous history of
hypertension for 7 years and took type of medication but she never control to health
care for her condition. She stated that she had stroke in 2012.
She stated that she had habit to drink coffee 3 glass/days. She rarely to do a physical
exercise and not doing anything at home.

Personal and Social History

PHYSICAL EXAMINATION
General Condition
Awareness : Compos mentis
Pain impression : Moderate
Sleep : Supine, 2 pillows on a bed
Height : 160 cm
Weight : 90 kilograms
BMI : 35,1 kg/m2
Nutritional level : Obesity II

Vital Signs
Blood pressure : 150/80 mmHg
Pulse : 72 beats/minute
Respiration : 24 breaths/minute
Respiratory Type : Thoracoabdominal
Temperature : 36,7°C

Specific Examination
Head
a. Skull : Normocephal
b. Face : Puffy Face (-)
c. Eyes:
- Eyelids : Eyelid edema -/-
- Sclera : Icteric -/-
- Conjunctiva : Anemic -/-
- Pupil : Round, Isochore ± 3 mm
- Eye Lens : No abnomarlities
d. Ears : No abnormalities
e. Nose : No abnormalities
f. Mouth:
- Lips : No abnormalities
- Gums and teeth : No abnormalities
- Tongue : No abnormalities
- Oral cavity : No abnormalities
Neck
a. Inspection
- Trachea : Deviation (-)
- Thyroid gland : No enlargement
- Lymph Nodes : No enlargement
- Widening of vein : Visible
b. Palpation
- Thyroid gland : No enlargement
- Lymph Nodes : Not palpable
- Tumor : None
- Stiff neck : None
- Jugular venous pressure : 5 + 3 cmH2O
- HJR : Negative

Armpit : No abnormalities
 - Tumors : None
Anterior Thorax
a. Inspection
- Shape : Symmetric
- Movement : Symmetric
- Intercostal space : Not widened or narrowed
- Skin : No abnormalities
- Musculature : No abnormalities
- Ictus cordis : Visible
- Mammae : No abnormalities
b. Palpation
- Skin : No abnormalities
- Musculature : No abnormalities
- Intercostal space : Not widened or narrowed
- Vocal Fremitus : Normal, right = left
- Apical Impulse : Palpable
o Localization: ICS VI, 2 cm lateral from the
left midclavicular line
o Intensity : Strong
o Thrill : No thrill
c. Percussion
- Comparison percussion : Sonor, right = left
- Heart Boundaries :
Upper right = ICS II right parasternal line
Upper left = ICS II left parasternal line
Lower right = ICS IV, right sternal line
Lower left = ICS VI, left anterior axillary line 2 dm lateral
d. Auscultation
- Respiratory Sounds : Rhonchi basal +/+, wheezing -/-
- Vocal resonance : Normal, right = left
- Heart sounds : S1 & S2 regular, murmur (-), gallop (-)
Posterior Thorax
a. Inspection
- Shape : Symmetric
- Movement : Symmetric
- Skin : No abnormalities
- Musculature : No abnormalities
b. Palpation
- Intercostal space : Not widened or narrowed
- Musculature : No abnormalities
- Vocal Fremitus : Normal, right = left
c. Percussion
- Comparison percussion: Sonor, right = left
- Lower boundaries: Left: XI Thoracic Vertebrae
Right: X Thoracic Vertebrae
d. Auscultation
- Respiratory Sounds : Rhonchi basal +/+, wheezing -/-
- Vocal resonance : Normal, right = left

Abdomen
a. Inspection
- Shape : Flat
- Skin : No abnormalities
- Umbilicus : Indented
b. Auscultation
- Bowel : (+) normal, 10 times/minute
- Additional Sounds : None
c. Palpation
- Wall : Smooth, fluid wave (-)
- Tenderness : None
- Mass / tumor : None
- Liver : Not Palpable
 - Spleen : Not palpable
- Troube space : Empty
- Kidney : Ballotement -/-
d. Percussion
- Percussion sound: Tympani
- CVA pain: -/-

Extremities:
a. Upper: Warm skin, CRT< 2 seconds, clubbing fingers (-/-)
b. Lower: Warm skin, CRT<2 seconds, Pitting edema (+/+)

DIAGNOSTIC TESTS

Laboratory Results
Blood Test
Hemoglobin : 13,4 g/dL
Erythrocyte : 4,6x106 /uL
Leukocyte : 7,1 x103/uL
Hematocrit : 39 %
Thrombocyte : 211 x103/uL

Diff Count
Basophil : 0,6%
Eosinophil : 1,4%
Segment : 49,4%
Lymphocyte : 42 %
Monocyte : 6,6%

Renal Function
Urea : 26 mg/dl
Creatinine : 1,5 mg/dl
Electrolyte
Natrium : 143 mmol/L
Potassium : 3,4 mmol/L
Chloride : 103 mmol/L

Profile Lipid
Triglyceride : 190 mg/dl
LDL-Cholesterol : 120 mg/dl

Electrocardiogram (ECG)
ECG Interpretation:
Heart Rate : 75 beats/minute
Rhythm : Regular Sinus Rhythm
Axis : Normal
P wave : Normal
PR Interval : normal
QRS wave : normal
Q patologis :-
ST segment : normal
T wave : normal

X-Ray Interpretation:
Appearance of the Heart: Cardiomegaly
DIAGNOSIS
Differential Diagnosis:
1. Congestive Heart Failure NYHA Stage IV
Clinical Diagnosis : CHF NYHA Stage IV
Anatomical Diagnosis : cardiomegaly
Etiological : hypertensive heart disease

TREATMENT
Non-Pharmacological Treatment:
a. Oxygen 2-4L via Nasal Cannula
b. Lifestyle Changes
1. Heart-healthy Diet: Eat an overall healthy dietary pattern that emphasizes a
variety of fruits and vegetables, whole grains, low-fat dairy products, skinless
poultry and fish, nuts and legumes, and non-tropical vegetable oils. Also, limit
saturated fat, trans fat, cholesterol, sodium, red meat, sweets and sugar-sweetened
beverages.
2. Aim for a Healthy Weight: Being obese means that there is more body fat within
the body. With an increase in weight the patient is more likely to develop other
complications like coronary heart disease, high blood pressure, type 2 diabetes,
breathing problems, and certain cancers. Health professionals recommend losing 5
to 10 percent of the patient's initial weight over the course of about 6 months. A
loss of just 3 to 5 percent of the patient's current weight can lower triglycerides and
glucose levels in the blood, as well as lower the risk of developing type 2 diabetes.
Losing more than 3 to 5 percent can improve blood pressure readings, lower bad
LDL cholesterol, and increase good HDL cholesterol.

Pharmacological Treatment:
1. Furosemide: A diuretic which increase urination to help the kidneys eliminate
excess fluid from the body.
2. Candesartan: An Angiotensin II Receptor Blocker that help relax blood vessels,
which lowers blood pressure and makes it easier for the heart to pump blood.
3. Digoxin: A drug that increases the strength and efficiency of heart contractions,
and is useful in the treatment of heart failure and control the rate and rhythm of the
heart.
4. Clopidogrel: An antiplatelet drug which works by blocking platelets from
sticking together and prevents them from forming harmful clots which could lead
to a heart attack or stroke. It helps keep blood flowing smoothly in your body.

Prescription
R/ Furosemide 40mg tab No.VII
S 1 dd 1
R/ Candesartan 4mg tab No. VII
S 1 dd 1
R/ Clopidogrel 75 mg tab No. VII
S 1 dd 1
PROGNOSIS
Quo ad Vitam: dubia ad bonam
Quo ad Functionam: dubia ad malam