presented with dyspnea for 4 weeks during which time she
developed dyspnea and fatigue on minimal exertion and even at rest. She also complained of orthopnea and reported that most of the past week she slept sitting in a recliner. Prior to sleeping on a recliner, she had had one episode of paroxysmal noctuurnal dyspnea. Her past medical history was remarkable for hypertension. She denied chest pain, palpitation or dizziness. She also reported right upper quadrant pain associated with nausea and loss of appetite but no vomiting. She had chronic leg swelling which has gotten so severe over the past several weeks that she could not wear her shoes. She responded to her worsening symptoms by retricting her activities and did not see her physician. At the emergency department, her jugular venous pressure was elevated at 15 cm of water. She had positive hepatojugular reflux, a right-sided third heart sound and an enlarged soft tender liver. She had no pulmonary rales of wheezing. She had severe bilateral pitting edema in both of her legs up to mid-thight areas with multiple blisters over lower legs. She also had evidence of venous insufficiency with brown pigmentation and induration of skin. A loud second heart sound at left fourth intercostal space suggested that her estimated pulmonary artery systolic pressure was elevated at 40-45 mm Hg. She had normal sinus rhythm by an electrocardiogram. Her chest radiograph was remarkable for marke cardiomegaly and pulmonary venous congestion. Her prior left ventricular ejection fraction was unknown and subsequent echocardiogram revealed a left ventriculer ejection fraction >55%. Seorang wanita 84 tahun diketahui gagal jantung datang dengan sesak nafas selama 4 minggu di rasakan sesak nafas dan kelelahan pada aktifitas yang minimal bahkan pada saat istrahat. Dia juga mengeluhkan orthopnea dan melaporkan bahwa pada minggu-minggu terakhir ia lebih banyak tidur dengan posisi duduk di kursi. Sebelum tidur di kursi, dia telah memiliki satu episode paroxysmal noctuurnal dyspnea. Riwayat penyakit terakhirnya yaitu hipertensi yang parah. Dia menyangkal adanya nyeri dada, palpitasi atau pusing. Dia juga mengeluhkan nyeri di kuadran kanan atas yang berkaitan dengan kelelahan dan nausea tetapi tidak muntah. Dia mempunyai pembengkakan kaki yang kronik yang sudah begitu parah selama beberapa minggu terakhir dia tidak bisa menggunakan sepatu. Dia merespon gejalanya yang semakin memburuk dengan membatasi aktifitasnya dan tidak menemui dokternya. Di UDG, tekanan vena jugularnya meningkat pada 15 cm of water. Dia memiliki reflux hepatojugular yang positif, bunyi jantung ketiga bagian kanan dan hepar membesar dan teraba lunak. Dia tidak mempunyai bunyi paru wheezing. Dia memiliki pitting edema bilateral yang parah di kedua kakinya sampai dibagian pertengahan dengan banyak lecet diatas kakinya. Dia juga terbukti memiliki insufisiensi vena dengan pigmentasi coklat dan indurasi kulit. Bunyi jantung kedua pada ICS 4 mengarah pada perkiraan arteri puulmonari sistoliknya meningkat 40-50 mmHg. Dia memiliki irama sinus yang normal oleh EKG. Dari hasil rontgen dadanya didapatkan tanda kardiomegali dan kongesti vena pulmonal. Hasil fraksi ventrikular ejeksinya sebelumnya tidak diketahui dan ekokardiogram berikutnya mengungkapkan fraksi ejeksi ventrikel kiri >55%.