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Skenario Mrs. Cikya Mrs.

Cik Ya, 49 years woman, admited to hospital with the main chief complaint shortness of breath since yesterday. 2 months ago, patient felt edema on her leg, palpitation. She went to clinic, and got medicine without any further physical examination. Fortunately the symptoms relief. Since a month ago, she often felt fatigue and nausea. And one week ago she felt very tired and slept with 2 pillows, fever, cough, nausea and epigastric pain. Then she visited the same doctor but she just accepted drugs for gastric complaint and amoxicilin tab 3x500mg, ambroxol sirup 3xc and paracetamol 3x1 tab/day, pc. Previous history: Recurrent pharyngitis (+), asymetric and migratory arthritis of knee and ankle joint (+), family history of CAD (+). Menopause since 2 years ago. Physical exam: Orthopnoe, Ht 155 cm, Bw 70 kg, BP 110/70 mmHg, PR 115 bpm, irregular. RR 36x/m. Temperature 38,5 degree celcius. JVP 5+2, basal rales (+), wheezing (+). Heart: HR 128x/m, arythmic, left border 2 finger lateral LMC sinistra ICS V. Liver palpable 3 fingers below arcus costae and ankle edema. Labor: Hb 12,2g%, WBC 15.000, Trombosit 250.000, Diff count: 1/1/3/70/30/2 Total cholesterol 260 mg%, triglyceride 240mg%. Blood glucose 105 mg%. Glucose urine (-). SGOT 52U/L, SGPT 43 U/L, Total bilirubin 1,8 mg/dl, Ureum 40 mg/dl, creatinin 1,1 mg/dl, sodium 135 mmol/l, potasium 4 mmol/l. CK NAC 140 U/L, CK MB 25 U/L, Troponin 0,1 ng. Chest X-ray: CTR >50%, signs of chepalization. ECG: AF Rapid ventricular respons, left axis, 130 x/m, left atrial hiperthrofi, RAH, RVH, LV Strain. Echo: Wall motion normal, MS severe, vegetasi (+), MR mild, AR moderate, TR moderate, PH moderate, PR mild, ejection fraction 55% and thrombus attached to LA, efusi pericard minimal.

I.

TERM CLARIFICATION a. Shortness of breath b. Edema c. Palpitation d. Fatique e. Nausea f. Fever g. Cough h. Epigastric pain i. Amoxicillin

j. Ambroxol k. Paracetamol l. Pharyngitis m. Asymetric Arthritis n. Migratory Arthritis o. Orthopnoe p. Cephalization q. Basal Rales r. Arythmic s. SGOT t. SGPT u. CK NAC v. CK MB w. AF rapid venticular x. Left axis y. Vegetasi (+) z. PH Moderate aa. Thrombus bb. Efusi Pericard II. PROBLEM IDENTIFICATION a. Mrs Cik Ya, 49 year old women is complain shortness of breath since yesterday b. 2 months ago, patient felt edema on his leg, palpitation and got medicine without any further physical examination c. Since a month ago, she often felt fatique and nausea d. one weeks ago she felt very tired and slept 2 pillows, fever, cough, nausea, and epigastric pain e. she visited the same doctor but she accepted drug for gastric complaint and amoxicillin tab 3 x 500 mg, ambroxol sirup 3xc and paracetamol 3 x 1 tab/day, pc. f. Previous history : Recurrent pharyngitis (+), Asymetric and migratory arthritis of knee and ankle joint (+), family history of CAD (+). Menopause since 2 years ago g. Physical exam: Orthopnoe, Ht 155 cm, Bw 70 kg, BP 110/70 mmHg, PR 115 bpm, irregular. RR 36x/m. Temperature 38,5 degree celcius. JVP 5+2, basal rales (+), wheezing (+). Heart: HR 128x/m, arythmic, left border 2 finger lateral LMC sinistra ICS V. Liver palpable 3 fingers below arcus costae and ankle edema. h. Labor: Hb 12,2g%, WBC 15.000, Trombosit 250.000, Diff count: 1/1/3/70/30/2 Total cholesterol 260 mg%, triglyceride 240mg%. Blood glucose 105 mg%. Glucose urine (-). SGOT 52U/L, SGPT 43 U/L, Total bilirubin 1,8 mg/dl, Ureum 40 mg/dl, creatinin 1,1 mg/dl, sodium 135 mmol/l, potasium 4 mmol/l. CK NAC 140 U/L, CK MB 25 U/L, Troponin 0,1 ng. i. Chest X-ray: CTR >50%, signs of chepalization. ECG: AF rapid ventricular Respon, Left axis, 130x/mnt, LAH, RAH, RVH, LV strain Echo: Wall motion normal, MS

severe, vegetasi (+), MR mild, AR moderate, TR moderate, PH moderate, PR mild, ejection fraction 55% and thrombus attached to LA, efusi pericard minimal. III. PROBLEM ANALYSIS a. Is there any correllation between her age, gender, and her condition? b. What is the cause of shortness of breath? c. What is mechanism shortness of breath? d. What cause & mechanism of edema on his leg, palpitation? e. What cause & mechanism of fatique and nausea? f. What cause & mechanism tired, fever, cough &epigastric pain? g. Why she need two pillow for her sleep? h. What cause and mechanism recurrent pharyngitis, asymetric, and migratory arthritis of knee and ankle knee? i. What is cause and mechanism of menopause? j. What is the correlation between her previous history and her condition? k. What is the pharmacokinetics of the drugs? l. What is the effect and side effect of the drugs? m. Interaction between the drugs? n. What is the etiologi of CAD? o. Is there any possibility that CAD can be inherited? p. What is the correlation between her family history and his condition now? q. What is the interpretation & mechanism of keadaan umum? r. What is the interpretation & mechanism of vital sign? s. What is the interpretation & mechanism of pemeriksaan khusus? t. What is the correlation between her physical exam and his condition? u. What is the interpretation and mechanism of lab test? v. What is the interpretation and mechanism of radiology? w. What is the interpretation and mechanism of ECG ? x. What is the interpretation and mechanism of Echo? y. What is the correlation between her condition with her lab test? z. What is the correlation between her condition with radiology? aa. What is the correlation between her condition with ECG ? bb. What is the correlation between her condition with Echo? cc. What is the DD? dd. What is the Additional test? ee. What is the WD? ff. What is the Patofisiology? gg. What is the Management? hh. What is the Complication? ii. What is the Prognosis? jj. What is the KDU? IV. HYPOTHESIS Mrs Cik Ya, 49 years old suffered from Congestive heart disease due to reumatic heart disease

V. SYNTHESIS A. Anatomi dari Jantung Jantung terdiri dari 3 lapisan jaringan yaitu: - Perikardium, terdiri dari 2 kantung yang luar yaitu jaringan fibrosa dan yang dalam yaitu membrane serosa - Myokardium, terdiri dari otot jantung yang hanya ditemukan di jantung. Masingmasing serat (sel otot) terdiri dari satu nucleus dan satu atau lebih cabang. - Endokardium, membatasi miokardium dan katum jantung. Terdiri dari sel epitel selapis. B. Index Massa Tubuh (IMT) CikYa BMI= =70 =29,13 CikYaObese I C. Mekanisme Sign dan Symptom -Shortness of breath (dypsnea)

-Oedem in leg
CHF EDV, Tek.pengisian, HR, kontraktilitas miokardium CO, BP ↓ Baroreseptor Pusat vasomotor

Konstriksi arteri dan vena ↓ Aliran plasma & perfusi darah ginjal

Renin & Angiotensinogen

Angiotensin I & II

Masukan air

otak Adrenal korteks

↓Retensi H2O & Na

Aldosteron

↑ Cairan intraekstravaskuler Ketidakseimbangan vol.cairan dan tekanan

P.Hidrostatik kapiler ↑

edema

-Fatigue

-Nausea

-hubungan sign dan symptom

Correlation of all Symptoms
Inflammation Streptococcus β hemolyticus group A Infects pharynx Go to circulation Infect heart FEVER

Destruction of mitral valve

fibrous formation
Mitral stenosis Blood go to LA

↓CO

↑Pressure of LA

Blood go to lungs
BREATH SHORTNESS COUGH

RA Accumulated in liver Hepatomegaly

Blood go to RV go to lower extremities EDEMA ON LEG NAUSEA EPIGASTRIC PAIN Anaerob metabolism HR↑

Lungs edema

Press stomach Supply of O2↓

Lactate accumulation ↑energy used

Stimulate hypothalamus

Vasoconstriction PALPITATION Sebacea gland Sweating

FATIGUE

D. Obat yang digunakan oleh Mrs. Cikya sebelumnya: There are four medicines that the doctor use, they are: 1. Amoxicillin  Mechanism of action  Inhibit the synthesis of bacteria cell wall  Half life  1.6 hours  Absorption  good in intestine, stabile in acid condition, the absorption is same when take before and after meal.  Excrete  in urine  Doses  3x250-500mg  Side effect : 1. GI disturbance  2. Hypersensitive  3. Serum sickness  Contraindication  renal disorder 2. Paracetamol  Mechanism of action  inhibit the synthesis and work of prostaglandin  Half life  2-3 hours  Absorption  Good blank stomachs, metabolized by liver microsomal enzyme  become sulfate and gluconoride.  Excrete  in urine  Doses  3-4x325-500mg  Side effect : 1. Hepatotoxic 2. Liver necrosis  Contraindication  renal disorder  3. Drugs for gastric complain  Include: antacids, stomach anti secretion, and mucosal protective  Mechanism of action:

 React with HCl in stomach to make salt and water (neutralization)  Inhibit histamine release by blocking H2 receptors  Inhibit proton pump (H+/K+ ATP-ase)  Side effect:  Change of colon habit  Kation over absorption  Systemic Alkalosis  Contraindication:  Renal disorder  CHF ( if use high doses of NaHCO3) 4. Ambroxol  Mechanism of action  enhance mucolytic by altering molecular of mucous  Side effect  mild GI disturbance  Contraindication  gastric ulcer, 1st trimester of pregnancy What is the correlation between all of the symptoms? (2 months ago  yesterday) E. Pharingitis Faringitis adalah infeksi oleh Grup A Hemolytic Streptococcus Beta yang nantinya akan menyebabkan demam rematik. Radang tenggorokan bagian belakang langit-langit lunak (faring). Streptolysin O dapat menyebabkan respons antibodi yang menunjukkan infeksi streptokokus. Streptococcus ini akan menempel pada dinding sel epithel dari membran mukosa di saluran pernapasan. Symptom: - Fever - headache - muscle and joints aching - tenderness of cervical lymph nodes - tonsillar swelling F. Hubungan menopause dgn kasus Level of estrogen in blood circulation will decrease.Estrogen playing a vital role by guarding artery free from atherosclerotic plague (lipid,cholesterol,dead tissue cell) with increasing high density lipoprotein amount.

G. Cara Mendiagnosa - Anamnesis a. Identitas b. Keluhan c. Riwayat penyakit sebelumnya (infeksi) d. Riwayat penyakit dalam keluarga e. Riwayat pengobatan: obat yang digunakan, kepatuhan f. Aktivitas harian g. Riwayat konsumsi alcohol dan merokok h. Factor resiko

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Pemeriksaan Fisik a. Status mental b. Vital sign  Tekanan darah 110/70 mmHg  normal  HR 115 Bpm  takikardi normalnya 60-100bpm  RR 36x/menittakipneu normalnya 16-24 bpm c. Status gizi BMI= =29,13obese 1 d. Leher JVP (5+2) mmH2Onormal (5+5)batas normal e. Dada  Basal rales (+)  adanya bunyi ronkhi yang diperiksa dengan stetoscope didaerah torak, ronkhi berupa suara serak2 seperti ada air, menandakan adanya edema didaerah paru-paru.  wheezing  mengi, menandakan pasien mengalami sesak nafas. f. Abdomen  liver teraba 3 jari dibawah arcus costae  hepatomegali g. Ekstremitas  minimal ankle edema  adanya edema dijaringan, telah ada gagal janrtung kanan dan perkembangan dari gagal jantung kiri

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Pemeriksaan Laboratorium
Total cholesterol Triglyseride Blood glucose Glucose urine SGOT SGPT Total bilirubin CK NAC CK MB Troponin Hasil 260 mg% 240 mg% 105 mg% (-) 52 U/L 43 U/L 1.8 mg/dl 140 U/L 25 U/L 0.1 ng/ml Nilai normal < 200 mg% < 200 mg% < 200 mg% (-) 10-34 U/L 0-40 U/L 0.2-1.2 mg/dl 38-174 U/L < 25 U/L < 0.03 ng/ml Interpretasi Hyperlipidemia Lipoproteinemia normal Normal heart@liver damaged IMA,hepatitis,CHF Liver disease Normal 3-12j setelah IMA 2-8j setelah IMA

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WBC15.000 (The normal range for WBC count is 4,300 to 10,800) Pemeriksaan penunjang  Chest XRay - CTR (cardio-thorax ratio) = lebar jantung / lebar rongga thorax x 100 - CTR > 50% = cardiomegaly  ECG - AF rapid ventricular respon = AF menandakan adanya gangguan di atrium - Left axis = Pada keadaan ini terjadi deviasi aksis kiri ( > 30o). - LAH : Adanya pembesaran atrium kiri

- RAH : Adanya pembesaran atrium kanan - RVH : Adanya pembesaran ventrikel kanan - LV Strain: Menunjukkan adanya pembesaran ventrikel kiri  Echocardiography - Thrombus attached to LA: There is the blood clots in the left atrium that can be caused by mitral stenosis. - Ejection fraction 55%: it’s low ejection fraction. Normal : 65±8 % - Efusi Perikard minimal :The accumultion of fluid in the pericardium. The compesation of pericardium effusion is tachycardia. - Vegetasi (+) : There is infective in endocarditis. The complication of endocarditis is valve regurgitation and abcess. H. Diagnosis Banding
DISEASE Shortness of breath Fatique Nausea Chest pain Fever Cough Palpitation

Aortic stenosis Endocarditis Pericarditis Mitral valve prolapse Myocarditis Congestive heart failure Rhuematic heart diseases CHF: Mayor Criteria

yes Yes Yes Yes

Yes Yes Yes Yes

No No No No

Yes No No Yes

No Yes Yes No

No Yes Yes No

Yes No No No

Yes Yes

Yes Yes

No No

Yes Yes

Yes Yes

No Yes

No No

Yes

Yes

Yes

No

Yes

Yes

Yes

Minor Criteria 1. Ankle edema 2. Cough at night 3. Hepatomegaly 4. Pleura effusion 5. Tachycardia >120bpm

1. Paroxysmal Nocturnal Dypsnea 2. JVP ↑ 3. Basal rales (+) 4. Cardiomegaly 5. Acute pulmonary edema

6. Gallop S3 7. Vena pressure >16cmH2O 8. Cardio jugular reflux RHD: Mayor Criteria 1. Carditis 2. Migratory polyathritis 3. Subcutaneous nodules 4. Sydenham’s chorea 5. Erythema marginatum -2 kriteria mayor -atau 1 kriteria mayor+2kriteria minor Minor Criteria 1. Fever 2. Arthralgia 3. Leucocytes ↑ 4. LED ↑

I. Diagnosis Kerja CHF karena RHD CHF: Etiologi Umum: - PJK - Infark miokardium - Hipertensi - Katup jantung pulmonal - Diabetes
Faktor Resiko:

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Diabetes Merokok Hipertensi Obat Obesitas Deficiency vitamin Lemah Orthopnea Fatigue Nausea Dyspnea Ascites Edema

Manifestasi klinis:

RHD:

Hepatomegali JVP meningkat Takikardia

 

Etiologi: streptococcus grup A-β hemoliticus Patogenesis: Streptococcus Group A-β Hemoliticusinfeksi saluran pernafasanfaringitisrespon imun (ASTO-Antibodi Streptolisin O)antibodi yg ditujukan pada protein M Streptokokus A bereaksi silang dengan protein normal yang terdapat di jantung, sendi, dan jaringan lainRHD Manifestasi klinis: - Karditisperikarditis, miokarditis, endokarditis (pankarditis) - Poliartritis migransartralgia dan arthritis pada demam reumatik umumnya mengenai lebih dari 1 sendi dan berpindah-pindah - Khoreagangguan saraf yang mengakibatkan gerakan bagian-bagian tubuh yang tidak terkendali, lemah otot, dan gangguan emosi - Eritema marginatumkelainan berupa bercak kulit (rash) - Nodul subkutantonjolan2 keras di bawah kulit tanpa perubahan atau nyeri.

J. Management: - Untuk CHF: a. meningkatkan oksigenasi dengan pemberian oksigen dan menurunkan konsumsi O2 melalui istirahat/pembatasan aktivitas (ABC, infus cairan) b. memperbaiki kontraktilitas jantung
mengatasi keadaan yang reversible termasuk tirotoksitosis,miksedema dan aritmia digitalisasi

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dosis digitalis
   digoksin oral untuk digitalisasi cepat 0,5-2mg dalam 4-6 dosis selama 24 jama dan dilanjutkan 2x 0,5 mg selama 2-4 hari digoksin iv 0,75-1 dalam 4 mg dalam 4 dosis selama 24jam cedilanid iv 1,2-1,6mg dalam 24 jam

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dosis penunjang untuk gagal jantung; digoksin 0,25 mg sehari. Untuk pasien usia lanjut dan gagal ginjal dosis

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dosis penunjang dioksin untuk fibrilasi untuk fibrilasi atrium 0,25mg digitalisasi cepat diberikan untuk mengatasi edema pulmonal akut yang berat :
  digoksin : 1- 1,5 mg iv perlahan-lahan cedilanid : 0,4-0,8mg iv perlahan-lahan

c. menurunkan beban jantung
 menrunkan beban awal dengan diet rendah garam, diuretic dan vasodilator a. diet rendah garam pada gagal jantung dengan NYHA kelas IV,penggunaan diuretic, digoksin dan penghambat ACE diperlukan mengingat usia harapan hidup yang pendek. Untuk gagal jantung kelas II dan III diberikan : 1. diuretic dalam dosis yang rendah atau menengah (furosemid 40-80mg) 2. digoksin pada pasien dengan fibrilasi atrium maupun kelainan irama sinus 3. penghambat ACE (katropil mulai dari dosis 2x6,25 mg atau secara penghambat ACE yang lain, dosis ditingkatkan secara bertahapdengan memperhatikan tekanan darah pasien) ; isosorbid dinitrat (ISND) pada pasien dengan kemampuan aktivitas yang terganggu atau adanya iskemia yang menetap, dosis dimulai 3x 10-15 mg. Semua obat ini harus dititrasi secara bertahap. b. Diuretik Yang digunakan furosemid 40-80 mg. Dosis penunjang rata-rata 20 mg. efek samping berupa hipokalemia dan dapat diatasi dengan suplai garam kalium atau diganti dengan sprinokolakton. Diuretic lain yan dapat digunakan adalah hidroklorotiazid, klortalidon, triamteren,amilorid dan asam etakrinat. c. vasodilator

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Nitrogliserin 0,4-0,6 mg sublingual atau 0,2-2 ug/kgBB/menit iv Nitroprusid 0,5-1 ug/ k BB/menit iv Prazosin per oral 2- 5 mg Penghambat ACE ; katropil2x 6,25 mg

Untuk RHD: a. Karditis dan kardiomegali tirah baring>6 minggu, mobilisasi bertahap>12 minggu, dan diberikan prednisone 2mg/kgBB/hari selama 2 minggu dan diturunkan bertahap, serta salisilat 75mg/kgBB/hari mulai minggu ke 3 sampai minggu ke 6. b. Khoreaklorpromazin, diazepam, haloperidol

K. Komplikasi - Stroke - Kematian mendadak - Cardiomyopathy. - Destroying of some organ function because of edema

VI. Prognosis Dubia at malam Progosis gagal jantung berkaitan dengan derajat keparahannya. Kematian dapat terjadi karena gagal jantung progresif atau secara mendadak (diduga karena aritmia) dengan frekuensi yang kurang lebih sama VII. Prevention and Education a. Prevention o Pencegahan terhadap endokarditis infektif diberikan pada setiap tindakan operatif seperti pencabutan gigi, luka, dan sebagainya. o pencegahan emboli sistemik antikoagulan warfarin o upaya pencegahan demam reumatik berulangparenteral penisilin G b. Education o Memberitahu pasien tentang gejala-gejala terulang kembali rheumatic fever o keyakinan dan ketaatan pasien untuk pencegahan sekunder ini secara spontan dan penuh pengertian VIII. KDU 3B able to make clinical diagnosis based on physical examination and additional examination. Doctor could do preemptive therapy and refers to relevant specialist(emergency case)