CHAPTER I INTRODUCTION
Congestive heart failure is defined as ³the state in which the heart is unable to pump blood at a rate adequate for satisfying the requirements of the tissues with function parameters remaining within normal limits usually accompanied by effort intolerance, fluid retention, and reduced longevity´ (Denolin, 1983, p. 445). Currently, congestive heart failure or heart failure, continues to be a major public health problem worldwide. It is the leading cause of morbidity and mortality in most developed countries. According to the American Heart Association (2001), approximately 5 million patients have heart failure and nearly 550,000 new patients are diagnosed each year. In addition, nearly 300,000 patients die from heart failure yearly. In Indonesia, cardiovascular disease is the third most frequent disease following infectious disease and TBC.
This paper is a case report about Mrs.N, a 65 year old female, currently diagnosed with Congestive Heart Failure et causa Hypertension Heart Disease. Its purpose is to review the clinical manifestations, pathophysiology, preanalytical factors, and treatment in a congestive heart failure patient.
This case report is significant to our future medical care because it helps stress the importance of identification and treatment of patients with heart. Also, it explores the need for a thorough case analysis of a client to deliver the best medical care.
heavy nape of neck and fatigue were also present. fever. palpitation was present. epigastric pain. Sudden awakening of the patient after a couple hours of sleep with a feeling of breathlessness was absent.CHAPTER II CASE REPORT
2.2 Anamnesis (Auto and Alloanamnesis) Chief Complaint Shortness of breath that worsen since about 11 hours before admission. the patient complained shortness of breath while walking about 10 meters far. There was no complaint of cough. The patient rarely exercise.
History Of Illness A week before admission. there was no complained of defecation habits. The shortness of breath develops in the recumbent position was absent. Chest pain was absent. There was no complained of urinate and defecation habit. it was radiating to the back. 3-5 times of frequency. 3rd 2011
. chest pain was present. The patient also often awakens of sleeping for urinate. Complained about decreasing of appetite was present. swollen of the eyelids and extremities. the patient complained shortness of breath while she was praying. the patient still sleeping with one pillow. there was no history of smoking. palpitation presents with the exertional
dyspnea. and never produced ³wheez´ sounds. N : 65 years old : Female : 11 Ulu Palembang : Housewife : Moslem : Jan. vomit. it was also not influenced by weather and emotional condition. She decided to go to Mohammad Hoesin Hospital. abdomen bulging.1 Identification Name Age Sex Address Occupation Religion Hospitalized : Mrs. it was relieves by taken rest. nausea. About 11 hours before admission.
enough turgor. eflorescency and scar (-). equal : 32 x/m. cyanosis (-). subcutaneous nodul (-). History of hypertension is present since 10 years ago. 3 rd 2011) General Condition: General condition Sickness condition Conciousness Blood Pressure Pulse Rate RR Temperature Dehydration Body Weight Height BMI : Sick : Moderate sick : Compos Mentis : 160/ 80 mmHg : 100 x/m. icteric (-). taken captopril.
History of heart disease is absent. 3
. regular. she was go to community health center.History of Past Illness
History of a disease with the same complaints is denied. No history of diabetes
History of Family¶s Disease There is no patient¶s family who have the same complaints of the disease 2. pale on sole of feet (-).3 Physical Examination (Jan. thoracoabdominal type : 36. spider naevy (-).
Lymph nodes There are no enlargment of the lymph nodes on submandibular. normal pigmentation. and inguinal. neck. pale on palm of hands (-). axilaries. normal hair growth.83 (Normal Weight)
Keadaan Spesifik Skin The color of the skin is black-brown. but rarely control.7ºC : : 50 kg : 148 cm : 22.
stiffness (-). right margin at linea sternalis dextra. pupils were isokor. endopthalmus (-). symmetrical eyes movements. lymph nodes enlargment (-).
Nose Epistaxis (-). puffy face (-).
Thorax Normal shape. deformity (-). symmetrical. normal mucous layer. Good light response on both of eyes. thyroid gland enlargement (-). normal nasal septum. malar rash (-).
Neck Jugular venous pressure (5+2) cmH2 O.
Eyes Exopthalmus (-). spider naevy (-)
Lung Inspection Palpation Percussion Auscultation : Symmetrical of static and dynamic right and left were equal : Stem fremitus in both lung were equal : Sonor : Vesikuler (+) normal. wheezing (-)
Cor Inspection Palpation Percussion : Ictus cordis was not seen : Ictus cordis was not palpable : Upper heart margin at 2nd intercostal space. edematous of superior palpebrae (-). icteric sclera (-). decreasing hearing ability (-).Head Oval. wet soft rales (+) right lung parenchyma . alopecia (-). pale of conjungtiva palpebrae (-).
Ear Normal both of meatus accusticus externus. left margin at linea axillaris anterior sinistra 4
Abdomen Inspection Palpation Percussion Auscultation : Dome shaped.000/mm3) (<15 mm/h) (200. pretibial edema (+/+).000/mm3)
BSS Total cholesterol : 95 mg/dl : 198 mg/dl (<200 mg/dl)
. erythema of palm (-). 2011)
Complete Blood Count
Haemoglobin Haematocrite Leucocyte ESR Thrombocytes Diff Count: y y y Basofil Band Limphocytes : 0% (0-1%) : 1% (2-6%) : 16% (20-40%) Eosinofil Segment Monocytes : 2% (1-3%) : 77% (50-70%) : 4% (2-8%) : 11. pale on finger (-).Auscultation
: HR: 110x/m. varices (-). pale on sole of foot (-). tremor (-). pitting edema (-/-)
Lower Extremity Pain on joint (-). pressure pain(-).200/mm : 30 mm/h : 196. umbilicus flattened : Tender.4 Supportive Examination Laboratory Finding (January 3rd.6 g/dl : 34% : 12. liver and spleen was not palpable : Shifting dullness (+) : Normal bowel sound
Upper Extremity Paint on joint (-).000/mm
(12-16 g/dl) (40-48 vol%) (5000-10. Gallop (-). Murmur (-).000-500.
Genital Vulva edema (-)
Impression: Sinus rhythm Left Ventricular Hypertrophy
.3 mg/dl) (135-150 mmol/L) (3.0 mg/dl : 30 mg/dl : 0.5-5 mmol/L) (<40 U/I) (<41 U/I) (80-170 U/I) (<25 U/I)
Electrocardiography (January 4th.HDL-cholesterol LDL-cholesterol Triglyceride Uric acid Ureum Creatinine Natrium Kalium SGOT SGPT CK-NAK CK-MB
: 55 mg/dl : 104 mg/dl : 194 mg/dl : 3.7 mg/dl : 139 mmol/L : 3.6-6.0 mg/dl) (15-39 mg/dl) (0.9-1.3 mmol/L : 15 U/I :9 : 31 U/I : 20 U/I
(>55 mg/dl) (<130 mg dl) (<150 mg/dl) (F: 2.
Planning Examination Echocardiography Fluid balance monitoring
. intercostal spaces widening.Rontgen Thorax Postero-anterior
Photo condition is good. elongatio aorta. costophrenicus angle is fine. pulmonary parenchyma is normal. CTR > 50%. bones and soft tissues are in good condition. symmetric. trachea position in the middle.
radiologic finding was cardiomegaly. it was radiating to the back. pulse rate 100 bpm. 65 years old. rales (+).8. Physical examination found the blood pressure was 160/80 mmhg. thoracoabdominal. there was no history of smoking. nausea. The shortness of breath develops in the recumbent position was absent. Differential Diagnosis CHF e. Sudden awakening of the patient after a couple hours of sleep with a feeling of breathlessness was absent. There was no complaint of cough. 3-5 times of frequency.c ASHD + Hypertension stage I
2. O2 3 L/m 8
. There was no complained of urinate and defecation habit. Electrocardiography finding was left ventricular hypertrophy. it was relieves by taken rest. chest pain was present. abdomen bulging. upper heart margin at 2nd intercostal space. shifting dullness (+). palpitation was present. the patient complained shortness of breath while she was praying.5. Management Non-Pharmacology: 1. regular. The abdomen is bulging. Resume Has been examined a woman.
2. JVP (5+2) cmH2 O.c HHD + Hypertension stage I
2. heavy nape of neck and fatigue were also present. The patient rarely exercise. and never produced ³wheez´ sounds. right margin at linea sternalis dextra. The patient also often awakens of sleeping for urinate. palpitation presents with the exertional dyspnea. She decided to go to Mohammad Hoesin Hospital. there was no complained of defecation habits. epigastric pain. left margin at linea axillaris anterior sinistra. equal. oedema pretibial minimal. About 11 hours before admission. Bed rest 2. the patient still sleeping with one pillow. Working Diagnosis CHF e. Complained about decreasing of appetite was present.7. it was also not influenced by weather and emotional condition. swollen of the eyelids and extremities. fever. respiratory rate 32 bpm. anamnesis found that 1 week before admission. Chest pain was absent. the patient complained shortness of breath while walking about 10 meters far.2. vomit.6.
Tidak melakukan aktivitas berat.5 0C
Keadaan spesifik Kepala Conjungtiva palpebra pucat (-) Sklera ikterik(-) Leher JVP (5+2) cmH2O Pembesaran KGB (-) Thorax: Jantung HR96 x/ menit.3.9. sesuaikan antara yang masuk dan keluar. Furosemid injection 1 x 1 amp Captopril 3 x 12.
2. Prognosis Quo ad vitam Quo ad functionam : dunia ad bonam : dubia ad malam
Follow Up: Tanggal S O: Keadaan umum Kesadaran Tekanan darah Nadi Pernapasan Temperatur 4 Januari 2011 Sesak napas Tampak sakit sedang Compos mentis 150/90 mmHg 96 x/menit 28 x/ menit 36. micro. Diet Jantung III
y y y
IVFD D5% gtt X/m. murmur (-) gallop (-) 9
y y y
Minum jangan terlalu banyak. Hindari stress dan tenangkan pikiran.
vesikuler normal. hepar dan lien tidak teraba P : Shifting dullness (+) A : Bising usus (+) normal
Ekstremitas A P
Edema pretibia (+) minimal CHF ec. Furosemid injeksi 1 x 1 ampul Captopril 3 x 12. ronkhi di basal paru kanan dan kiri. mikro.5mg
Table of Fluid Balance Monitoring Days Intake Food 4/1/11 150 Drink 300 IVFD Total 250 700 Output Urinate Defecate CWL Total 450 300 750 -50 Selisih
. HHD Istirahat O2 3 liter/mnt Diet jantung III IVFD D5% gtt X/m. wheezing (-)
I : Cembung P : Lemas.
Ordinary physical activity does not cause undue fatigue. ³An array of different problems can cause congestive heart failure. dyspnea or anginal pain. If any physical activity is undertaken. or anginal pain. or heart muscle. especially if the pumping ability of the enlarged chamber greatly decreases. (2) A heart attack may also cause congestive failure. The development of heart failure depends on the extent and location of scarring. 1964). Eventually. dyspnea. but they usually have to 11
. the heart muscle works harder. The last classification is Class IV (Severe) are patients with cardiac disease where in there is inability to carry out any physical activity without discomfort. especially of the left ventricle. The heart¶s ability to perform decreases because ischemia results in the delivery of less oxygen and fewer nutrients to the heart muscle. dyspnea (shortness of breath). setting the stage for heart failure.
Causes. Because there is greater resistance against which the heart must pump. Class II (Mild) are patients with cardiac disease resulting in slight limitation of physical activity. Class III (Moderate) are patients with cardiac disease resulting in marked limitation of physical activity. this enlarged muscle tissue weakens. congestive heart failure may be classified into four functional states. They are comfortable at rest. Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. They are comfortable at rest. (3) Long-standing high blood pressure is another common cause of heart failure. This is usually caused by atherosclerosis. resulting in tissue death and scarring. discomfort is increased (New York Heart Association. According to the New York Heart Association (1964). but less than ordinary activity causes fatigue. On the other hand. palpitation. This results in an enlargement of the heart muscle. the heart¶s main pumping chamber. (4) Arrhythmias (irregular heartbeats) can also lead to heart failure. ³Class I (Mild) are patients with cardiac disease but without resulting limitatios of physical activity. palpitation. Ordinary physical activity results in fatigue. or anginal pain. palpitation.CHAPTER III THEORETICAL BACKGROUND
Classification. (1) Among them is coronary (ischemic) heart disease resulting from insufficient blood flow to the myocardium. the heart muscle is deprived of oxygen. the buildup of fatty substances or plaque on the walls of the arteries that carry blood to the heart muscle. During a heart attack.
2010). which separates the right atrium from the right ventricle. Sodium that would normally be eliminated through the urine remains in the body. 1992). This increases the heart¶s workload. (6) Cardiomyopathy.be severe and prolonged. The different types of edema possible are dependent edema. a condition known as kidney failure.
Manifestations. Pressure then builds up in the liver and the veins in the legs. The major symptoms of right-sided heart failure are edema and nocturia (Woods. 12
. edema that results in enlargement or swelling of the liver. Porth (2007) adds that right-sided failure occurs when there is resistance to the flow of blood from the right heart structures (right atrium. it is known as idiopathic heart failure´ (Soufer. fails to work properly. Soufer (1992) further elaborates the manifestations often seen in patients with heart failure. orthopnea. can also lead to heart failure. The other major symptoms of left-sided heart failure are fatigue. right ventricle. and must often occur in the presence of an already weakened heart. The problem may be congenital (inborn) or due to an infection such as endocarditis or rheumatic fever. 1992). When heart failure seems to have no known causes. and edema of the skin or soft tissues. thereby increasing risk of developing heart failure. et. alcohol abuse. This condition may also lower output of blood to the point of heart failure. This results in a backup of fluid and pressure in the veins that empty into the right side of the heart. which pumps it to the rest of the body´ (Porth. The liver enlarges and may become painful and swelling of the ankles or legs occurs (Soufer. (5) Valvular heart diseases are another cause of heart failure. and the sputum production that comes from pulmonary congestion (Soufer. with a rapid rate of more than 140 beats per minute. dyspnea. blood backs up in the vessels of the lungs. paroxysmal nocturnal dyspnea . Because congestive heart failure causes the body to fill with excess fluids. For example. The particular symptoms that an individual experiences are determined by which side of the heart is involved in the heart failure. and sometimes fluid is forced out of the lung vessels and into the breathing spaces themselves. When the left side isn¶t pumping efficiently. and cocaine abuse. ascites. a disease of the heart muscle itself. 1992). 2007). pulmonary or lung artery) into the lungs or when the tricuspid valve. Causes of cardiomyopathy include infection. They change the pattern of filling and pumping of blood from the heart. which results when a narrowed or leaking valve fails to direct blood flow properly through the heart. the ³left atrium receives oxygenated blood from the lungs and passes it onto the left ventricle. This pulmonary congestion causes shortness of breath. al. the kidneys may not be able to dispose of the extra sodium and water.
and this contributes to their increased risk of thrombosis. Patients with heart failure and chronic venous insufficiency may also be immobile.5% in those without heart failure). (1) One of these are malignant ventricular arrhythmias which are commonin end stage heart failure. Mild to moderate heart failure is associated with an annual risk of stroke of about 1. 2000). sustained ventricular tachycardia occurs in up to10% of patients with advanced heart failure who are referred for cardiac transplantation(Watson. and associated atrial fibrillation.
Complications. rising to 4% in patients with severe heartfailure (Watson. Watson (2000) discovered that the common complications of heart failure include irregular heart rhythms or arrythmias. regional wall motion abnormalities (including formation of a left ventricular aneurysm). these arrhythmias often havemechanisms in scarred myocardial tissue. (4) Organ dysfunction occurs when there is a decrease in theoxygen supply to the different organ tissues in the body.compensatory mechanisms act but eventually decompensate leading to dysfunction of organs (Porth. thromboembolism and organdysfunctions. with an overall estimated annual incidence of approximately 2% (Watson. Because of the lack of oxygen. Factors contributing to the increased thromboembolic risk in patients with heart failure include low cardiac output (with relative stasis of blood in dilated cardiac chambers).5% (compared with a risk ofless than 0. For example. stroke. Congestive heart failure predisposes to (2) stroke and (3) thromboembolism. 2000). including deep venous thrombosis and pulmonary embolism. 2000). 2007).
. thereby aggravating the problem of excess fluid associated with congestive heart failure (Soufer. In patients with ischemic heart disease.causing it to retain even more water. 1992). An episode of sustained ventricular tachycardia indicates a high risk for recurrent ventricular arrhythmias and sudden cardiac death.
hepatomegaly. class 2 symptom appear in moderate activity. and also from liver. Based on anamneses and physical examination with supporting investigation the
dyspnea that come from the lung. ronki paru.
. dyspnea d'effort. cheyne-stokes respiration). class 3 symptom is appearing in light activity and class 4 symptom is appear at the (time) of rest in this patient dyspnea is appear at the (time) of activity (class 2). From result anamneses and physical examination in this patient were found dyspnea d'effort. dyspnea and cough. caused by impairment of heart structure and function. pleural effusion. refluks hepatojugular. fatigue. paroxysmal nocturnal dypsnea. ascites. which is heart incapable to pump the blood to fulfill the need metabolic tissue. The dyspnea be espoused oedema can come from pulmo. palpitation. has been described the clinical feature of left heart failure are weakness. orthopnea. wet soft rales at basal pulmo. menytensi vena neck. cheyne-stokes respiration) and fatigue (at rest or activity). soft wet rales at basal pulmo. acites. acute pulmo oedema. dam vena jugularis Congestive heart failure is the combination from both of heart failure clinical types. increasing of jugular venous pressure. kidney. takhikardia. minor criteria shaped oedema extremity. dyspnea (dyspnea d'effort. additional heart sound (heart sound III) and heart expansion. gallop s3. vena jugularis dam. The right heart failure with heel oedema phenomenon and leg oedema. vital capacity depreciation. heart expansion. cardiomegaly. Reviewed from the aspect of clinical manifestation according to the
symptomatologist. tachycardi (> 120 x/minute)s. fatigue. hepatomegaly. Based on classification New York Heart Association as 4 class (NYHA1 where -4) dyspnea and fatigue as evaluation. In class 1 there is no complaint. Heart failure is marked by shortness of breath (dyspnea d'effort. Based on criteria framingham minimal one major criteria and two minor criterias that is: major criteria shaped paroksisimal nocturnal menypneu. kidney. heart. palpitation. also the objective sign is tachycardia. orthopnea. paroxysmal nocturnal dypsnea. nighttime cough. and liver can be ruled out. and oedema pretibial minimal so that fulfil criteria clinical
description congestive heart failure.CHAPTER IV CASE ANALYSIS
Heart failure is clinical syndrome (a group of signs and symptoms).
Longstanding high blood pressure is another common cause of heart failure. Eventually. clinical manifestation and the severity of heart failure. Because there is greater resistance against which the heart must pump. The anatomical diagnoses is based on
physical examination found of expansion of the heart which is confirmed by the rontgen thorax with impression is cardiomegaly Hypertension is considering as the etiology of the disease in this patient. haemodynamic. Therefore we conclude that the functional diagnoses is congestive heart failure. the heart muscle works harder. the heart¶s main pumping chamber. this enlarged muscle tissue weakens. Therapy consists of 5 components shaped
. The management of heart failure is depend on etiology. This results in an enlargement of the heart muscle.Farmingham¶s Score for this patient: Major Criteria " paroxysmal nocturnal dyspneu " vena neck distention " rales " cardiomegaly " acute pulmonary eodema " gallop s3 " increasing of jugular venous pressure " refluks hepatojugular (-) (-) (+) (-) (-) (-) (+) (-)
Minor Criteria " extremity oedema " nighttime cough " dyspneu d'effort " Hepatomegaly " pleural effusion (+) (-) (+) (-) (-)
" vital capacity depreciation 1/3 from normal (-) " takikardi (>120 x/minute) (-)
This patient got two major criterias and two minor criterias. setting the stage for heart failure. especially if the pumping ability of the enlarged chamber greatly decreases. especially of the left ventricle.
diet heart II is porridge filters. To determine heart pump ability is need to see the ejection fraction of the heart that can be maintained from echocardiology with clinical symptoms of congestive heart failure and OMI anteroseptal so that the result of 3 days of therapy doesn¶t show repairment but inclined to be worse. stop the bad habit that increase heart sickness appearance. the aim is to deacrease ascites with reducing heart load wi hout t reducing cardiac output. diet heart IV is rice food.handling in general. Diet heart consists of to diet heart I is liquid food. Diet that given in this patient is diets heart III because patient stills aware and may not do too much activity. Therapy that given is furosemid. salt degree restriction (Na) but this is not yet need because the medicine that chosen to treat the patient is to increase expenditure of Na.
. While captopril given is to demote the blood pressure. diet heart III is porridge. and restrain degree CHF. Therapy based on symptoms is the restriction of liquid intake because many liquid will be absorbed and total liquid will increase so that make the heart work heavier. base cure disease. prevent furthermore damage in heart. In general heart failure class 3 and 4 necessary to limit activity restly in place sleep but necessary to avoid to sleep long. because this patient is also suffered from hypertension stage 1. Prognosis maintained based on from heart pump ability for compensation with clinical symptoms repair after the therapy. Diet food in heart disease in hospital is diets heart.
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