By : Merdyana

Darkuthni
SUPERVISOR :
dr. Abdul Hakim Alkatiri, Sp.JP, FIHA

Name
No.MR
Age
Gender
Date of admittance

: Mr. A
: 393620
: 65 years old
: Male
: 1 July 2009

Chief complaint: Short of breathness

History taking:
Ocurred since seven days but worsen five days before came
to the hospital.
Precipitated by exercise and lying position, not by cold
weather and feel better after take a rest.
Sometimes he woke up at middle of night by his shortness of
breath and he slept with two pillows or more.
Chest pain is described as a sharp and burning sensation on
the middle of chest, referred to the left arm but not penetrate
to the lower back. Chest pain isnt continously, increased by
activity and relieved with rest.

Cough (+) with white sputum, blood (-).

Fever (-), headache (-), dizziness (-).
Nausea (+).
Vomiting (+) since two days before came
to the hospital after got meal and drink,
frequency 3-4x/day, containing remains
food and water.
Epigastric pain (+).
Defecation and urination are normal.

Patient had been admitted to AL Hospital for

two days with dyspepsia and given Ranitidine.

Suffering hypertension more than 5 years

without regular medication (Blood pressure
180/120 mmHg).

History of heart disease (-).

History of Diabetes mellitus (-).

Family history of heart disease and Diabetes

mellitus (-).

Gender : Male
Age
: 65 years old
Ex-Smoker until 10 years previously.
History of Hypertension for 5 years (+).

General Appearance :
Severe-illness/normal weight/conscious

Vital Sign :

Blood Pressure : 150/90 mmHg

Pulse
: 116 bpm, regular
Respiratory rate
: 32 tpm
Body temperature : 36,7 C (axilla)

Head Examination :

Eyes : anemia(-), icterus(-), cyanosis(-)

Neck : JVP R+1 cmH20

Thoracic Examination :

Inspection
: Symmetric sinistra et dextra
Palpation
: No mass, no tenderness
Percussion
: Sonor
Auscultation
: Breath Sound was bronchovesicular,
rales +/+ in the basal, wh -/-

Cardiac Examination :
Inspection
Palpation
Percussion

: Ictus Cordis wasnt visible

: Ictus Cordis wasnt palpable
: Cardiomegaly

Auscultation

: S1/S2 Regular, no murmur

Upper border
Lower border
Right border
Left border

:
:
:
:

ICS II sinistra
ICS V sinistra
right parasternalis line
3 cm for the left of medioclavicular line

Abdominal Examination :

Inspection : Normal
Palpation
: No mass palpable, no
tenderness,
the liver and spleen
unpalpable.
Percussion : Tympani , Ascites (-)
Auscultation
: peristaltic sound (+) ,
normal

Extremities :

Oedema pretibial -/-

Complete blood count

WBC:11.73 x103/ul ()
RBC: 4.06x106/ul
HGB: 13.0 gr/dl
HCT: 39.0%
PLT: 126x103/l
Electrolyte
Sodium: 127 mmol/l ()
Potassium : 4,6 mmol/l
Chloride: 103 mmol/l

Blood chemistry:
Ureum : 77 mg/dl ()
Creatinine : 0.9 mg/dl
SGOT : 700 u/dl ()
SGPT : 666 u/dl ()
CK: 339 u/dl ()
CK-MB : 67 u/dl ()

Sinus arrhythmia
Heart rate 100 bpm
Axis : Normoaxis
P-mitral
cRBBB
Inferior wall sub acute myocardium Infarct
Whole anterior wall myocardium ischemic

LV Dilatation
Global
Hypokinetic, EF
18%
MI mild
Doppler : E/A > 1

Conclusion:

LV Dilatation

Global
hypokinetic, EF
18%

MI mild

 Bronchitis
Cardiomegaly

with
dilatatio et elongatio
aortae
Atherosclerosis aortae

 CHF

NYHA III ec CAD

Cardiac Diet
O2 2-4 lpm
IVFD NaCl 0.09% 10 dpm
Sotatic 1amp/8 hours/iv
Aspilet 80 mg 2x1
Clopidrogel 75 mg 1x4
Captopril 25 mg 2x1
Fasorbid sublingual 5 mg
Single dose, continuously with
10 mg, 3x1
Lasix 2 amp/12 hours/iv
Laxadine syrup 3x1
Alprazolam 0,5 mg 0-0-1

HISTORY
TAKING
, 65 years with complain short of
breathness, precipated by exercise.
History of woke up in the middle of
night because of short of breathness
and slept with two pillows or more.
Cough PHYSICAL
(+), Chest pain (+). History of
EXAMINATION
hypertension
(+)
BP = 150/90 mmHg, Icterus, JVP R+1
cmH2O, rales +/+, cardiomegaly.
ADDITIONAL
EXAMINATION
Laboratorium : WBC 11.73 x103/ul, Sodium
127 mmol/l, Ureum 77 mg/dl, SGOT/SGPT
700/666 u/dl, CK: 339 u/dl, CK-MB : 67 u/dl.
ECG : Sinus arhythm, HR 100 bpm, Axis
LAD, P-mitral, cLBBB, Inferior wall sub
acute miokard Infarct, Whole anterior wall
miokard ischemic.
Echocardiogram : LV Dilatation, Global
hypokinetic, EF 18%, MI mild.
Thorax x-ray : Bronchitis, Cardiomegaly

CHF e.c
CAD

Risk Factors
Gender :
Male
Age, 65
years
Ex-smoker

Hypertension
hystory

The heart muscle

(myocardium) gets the
oxygen and other
nutrients it needs
topump blood from
coronary circulation.
Is a failure of coronary
circulation to supply
adequate circulation to
cardiac muscle and
surrounding tissue.

The cholesterol, scar

tissue(plaque) and calcium
content in the walls of the
coronary arteries
Wall of the coronay arteries
thicker and less elastic
When coronary artery had
stenosis or spasm, supply of
coronary artery could be
sufficient the requirement
chest pain (stable angina),
shortness of breath, heart
attack, and other symptoms.

The most common symptoms of coronary artery

disease (CAD) are:
Chest pain or chest discomfort (angina) or pain in
one or both arms or in the left shoulder, neck, jaw,
or back
Shortness of breath
In some people, the first sign of CAD is a heart
attack. A heart attack happens when plaque in a
coronary artery breaks apart, causing a blood clot
to form and block the artery.

The goals of treatment are to:

Relieve symptoms
Slow or stop atherosclerosis by controlling
or reducing the risk factors
Lower the risk of having blood clots form,
which can cause a heart attack
Widen or bypass clogged arteries

Lifestyle Changes
Eat a healthy diet
Quit smoking, if s/he smoke
Exercise
Lose weight, if s/he overweight or obese
Reduce stress

Medicines
Cholesterol-lowering medicines
Anticoagulants
Aspirin
ACE inhibitors
Beta blockers
Calcium channel blockers
Nitroglycerin
Long-acting nitrates
Thrombolytic agents

Special Procedures
Angioplasty
Coronary artery bypass surgery
Coronary brachytherapy
Laser revascularization
These may be used to treat CAD if
Medicines and lifestyle changes have not
improved the symptoms.
The symptoms are getting worse.
Some people may need to have angioplasty or
bypass surgery on an emergency basis during a
heart attack to limit damage to the heart.

Damage heart muscle HEART

FAILURE

O2 Carrying
capacity
Body Demand
Exercise

Congestive heart failure (CHF) is an

imbalance in pump function in which the
heart fails to maintain the circulation of
blood adequately, for the requirements of
metabolism of tissues

Hypertension,
Coronary heart
disease,
Myocardium
Infarction,
Cardiomyopathy,
Congenital heart
disease,
Valvular heart
disease,
Toxins,

Aortae Stenotic,
Arrhythmia,
Endocrinologic
disorders,
Genetic disorders,
Myocarditis,
perycarditis,
Thyrotoksichosis,
etc.

Clinical
Left HeartManifestation
Failure
Right Heart Failure

Dyspneau deffort
Ortopnea, PND
Oedema pulmonal (crackles)
Fatigue, pale skin
Cardiomegaly, tachycardia
Cough (frothy sputum)
Gallop S3

Jugular Vein distension

Perifer Oedema
Hepar Congestion
Ascites
Splenomegaly
Sweating >>

+
Congestive Heart Failure

Diagnose Framingham Criteria

2 major or 1 major + 2 minor criteria have to be present

concurrently.
* major or minor criteria: weight loss > 4.5 kg in 5 days in response
to treatment

NYHA Classification of Heart

Failure
I

No symptoms and no limitation in ordinary physical activity.

II

Mild symptoms and slight limitation during ordinary activity.

Comfortable at rest.

III Marked limitation in activity due to symptoms, even during

less-than-ordinary activity. Comfortable only at rest.
IV

Severe limitations. Experiences symptoms even while at

rest.

Quit smoking
If overweight, lose weight
Avoid or limit alcohol consumption
Avoid or limit caffeine
Eat a low-fat, low-sodium diet
Salt restriction ( <1gm/day)
Exercise individually or in a structured
rehabilitation program (under a physician's
guidance)
Reduce stress

Managing
contractility
-Cardiac glycosides
- adrenergic
-Phosphodiesterase
inhibitors

Managing
preload

Managing
afterload

-diuretic
-venodilators

-Ca2+
channel
blockers
-Anti
adrenergic
-Vasodilators

Neurohumoral
modulation
- blockers
-ACE
inhibitors
-Angiotensin
receptor
blockers