PULMONARY EMBOLISM + CHF NYHA IV ec HHD + PH SEVERE

Nurfitrianti (c11109300) Supervisor: dr. Muzakkir Amir, Sp.JP, FIHA, FICA

PATIENT IDENTITY
Name Gender Age Address Registration number Date of admission

: Ms.N : Female : 53 years old : Enrekang : 615504 : 26th July 2013

HISTORY TAKING
Chief complain : Unconsciousness Present illness history:

Patient was unconscious 2 hours before admitted to Wahidin Sudirohusodo Hospital. Unconsciousness was occur suddenly, and accompanied with shortness of breath, bluish color on lips and extremities. History of admitted in PCC Hospital with swelling on lower extremities, shortness of breath, and cough with white sputum, and diagnosed with Congestive Heart Failure. 2 hours before, patient suddenly unconscious, with shortness of breath, and bluish color on lips and lower extremities. And referred to Wahidin Sudirohusodo Hospital for further treatment. According to family, patient slept with 2-3 pillows during sleeping for 6 months and breathlessness in walking far distance. Since than patient do little activity and only eat and sleep in her house. No chest pain, palpitation, fever, nausea, and vomiting. Urination and defecation was normal

 Previous illness history:

- History of admitted in PCC Hospital on July 26th

2013 with swelling lower extremities and shortness of breath. Diagnosed as CHF - History of hypertension for 7 years, with highest blood pressure of systolic 240 mmHg. With irregular treatment. - History of heart disease for long time. - No history of Diabetes Mellitus

Physical Examination
General Status :

Moderate-illness/obese/unconscious
Vital Sign :
Blood Pressure

: 140/90 mmHg

Pulse
Respiratory rate

: 84 bpm, regular
: 29 tpm : 36,5 C

Body temperature

BMI : 32,4 kg/m2

Head Examination Eyes : anemic -/-, icterus -/ Lip : cyanosis (+) Neck : JVP R +1 cmH2O, lymphadenopathy (-) Chest Examination Inspection : symmetric R=L, normochest Palpation : mass (-), tenderness (-) Percussion : sonor Auscultation : breath sound : vesicular additional sound : ronchi -/wheezing -/-

Cardiac Examination Inspection : Ictus cordis wasnt visible Palpation : Ictus cordis wasnt palpable Percussion :
- Right border : right parasternalis line

- Left border : 1 finger to the lateral of left midclavicular line Auscultation : Regular of I/II heart sound

Abdominal Examination
- Inspection : flat and following breath movement - Auscultation : peristaltic sound (+) , normal - Palpation : liver and spleen unpalpable - Percussion : tympani, ascites (-)

Extremities
- Edema : Pretibial +/+ and dorsum pedis

LABORATORIUM FINDINGS
Test WBC
HGB HCT PLT RBC Ureum Creatinin SGOT SGPT 13,9 47 218 6,29 23 1,1 27 9

Result 6,35 x 106

Normal value 4,0-10,0 x 103

13,0-17,0 g/dl 40,0-54,0 % 150-500 x 103 4-6 x 106 10-50 md/dL <1,3 mg/dL <38 U/L <41 U/L

LABORATORIUM FINDINGS
Test Na K Cl Albumin PT APTT GDS 123 3,2 81 3,4 16,3 control 11,7 95,6 control 27,0 294 Result Normal value 136-145 mmol 3,5-5,1 mmol 97-111 mmol 3,5-5,5 g/dL 10-14 second 22-30 second 140 200 mg/dL

CK
CK-MB Troponin T

41
8,7 Negatif

L(<190); P(<167) U/L

<25 U/L <0,05

Analysis blood gases

Test pH pCO2 SO2 PO2 HCO3 Result 7,32 74,8 mmHg 91,6 51,5 30,0 80-100 mmHg 22-26 Normal value 7,35-7,45

ECG (29/07/13)

ECG interpretation
- Rhythm

- HR/QRS rate
- Axis - P wave - PR interval - QRS complex - ST segment

: Sinus rhythm : 75 bpm, rreguler : Right axis deviation : 0,12 s : 0,2 s : 0,08 s, V5 R/S <1 : ST depresion in lead II, : Inverted T wave

III, aVF - T wave

Conclusion:
Sinus rhythm, HR 75 bpm, right axis deviation, biatrial hypertrophy, right ventricular hypertrophy, inferior wall ischemic and injury.

CHEST X-RAY
Cardiomegaly with pulmonary edema

DIAGNOSIS
Suspect pulmonary embolism

CHF NYHA IV ec HHD

PH severe Elektrolyte imbalance Hyperglycemia CAP

INITIAL MANAGEMENT
O2 10 L/minute (via NRM) IVFD NaCl 0,9% 500 cc/24 jam Heart diet Heparin 5000 IU bolus/IV Heparin 1000 IU/jam/IV

Aspirin (Aspilet) 1x80 mg

Clopidogrel (Plavix) 1x75 mg Furosemide inj 2 A/12jm/IV

Dobutamin 5 mikro/SP

Tapp off Ceftriaxone inj 2 gr/24 jam/IV (Skin test)

PULMONARY EMBOLISM
Discussion

DEFENITION
Pulmonary embolism is a clinically significant obstruction of part or all of the pulmanary vascular tree, usually caused by thrombus from a distant site.

ETIOLOGY
The causes for pulmonary embolism are multifactorial and are not readily apparent in many cases. The causes described in the literature include the following: Venous stasis Hypercoagulable states Immobilization Surgery and trauma Pregnancy Oral contraceptives and estrogen replacement Malignancy Hereditary factors

RISK FACTORS MAJOR Surgery Major abdominal/pelvic surgery Orthopaedic surgery (especially lower limb) Post-operative intensive care

Obstetrics

Late pregnancy (higher incidence with multiple births) Caesarean section Pre-eclampsia Pelvic/abdominal Metastatic/advanced Fracture, varicose veins Hospitalization Institutional care

Malignancy

Lower limb problems Reduced mobility

MINOR

Cardiovascular

Congenital heart disease Congestive cardiac failure Hypertension Central venous access Superficial venous thrombosis Oral contraceptive pill (especially third-generation higher oestrogen containing) Hormone replacement therapy Occult malignancy Neurological disability Thrombotic disorders Obesity Inflammatory bowel disease Nephrotic syndrome Dialysis Myeloprofilerative disorders

Oestrogens

Miscellaneous

Pathophysiology
Decrease in blood flow below a certain critical

level. Increase in coagulability of blood. Damage of the vessel wall.

Pathophysiology

Symptoms and signs

- Symptoms: Shock Dyspneu Pleuritic pain Anterior chest pain Cough Hemoptysis Asymptomatic - Signs: Cyanosis Tachypneu Rales Tachycardia S4 Accentuated P2

Clinical probability scoring system

- Raised respiratory rate - Haemoptysis - Pleuritic chest pain Plus 2 other factors: 1. Absence of another reasonable clinical explanation 2. Presence of a major risk factor a) plus 1 and 2: HIGH pre-test clinical probability b) plus 1 or 2: INTERMEDIATE pre-test clinical probability c) alone: LOW pre-test clinical probability.

Wells Criteria
Clinical Signs and Symptoms of DVT? +3 (Calf tenderness, swelling >3cm, errythema, pitting edema affected leg only)

PE Is #1 Diagnosis, or Equally Likely

Heart Rate > 100 Immobilization at least 3 days, or Surgery in the Previous 4 weeks Previous, objectively diagnosed PE or DVT? Hemoptysis Malignancy w/ Rx within 6 mo, or palliative?

+3
+1.5 +1.5 +1.5 +1 +1

>6: 2 to 6: 2 or less:

High Risk Moderate Risk Low

Adapted with permission from Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED d-dimer. Thromb Haemost 2000;83:416-20.

Diagnostic test
Arterial blood gases

Cardiac Enzymes: Troponin

D-dimer EKG CXR Ultrasound Echocardiography Angiography

Management
Respiratory Support: Oxygen, intubation

Anticoagulation
Thrombolysis Embolectomy

Prognosis
The prognosis of patients with pulmonary embolism depends on 2 factors: the underlying disease state and appropriate diagnosis and treatment. Approximately 10% of patients who develop pulmonary embolism die within the first hour, and 30% die subsequently from recurrent embolism.

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