Congestive Heart

Failure (CHF)
Preceptor:
Dr. Hj. Ihsanil Husna, Sp.PD

Student Name:
Anugrah Dwi Riski (2013730011)

Clinical Internship Internal Medicine

Cempaka Putih Jakarta Islamic Hospital
2017
 Patient’s Medical Record
Identity
 Name : MR. M
 Age : 54 Year, 1 month, 30 days
 Place/DoB : Jakarta, April 07th 1963
 Sex : Male
 Occupation : -
 Adress : Percetakan Negara St. Numb. 26,
Johar Baru, Central Jakarta
 Date of admission: June, 5th 2017
 No. Med Rec : 007319xx
Anamnese
 Chief complain
Dispneu since 1 days ago.
 Another complain
feel burn in the chest area since 1 days ago
 History of Present illness
Patient came to RSIJ with Dyspnea since 1 day
before hospital admission. Dyspnea getting worse if he
go up stairs, getting better if patient take a rest. vomiting
one time. Before vomiting patient feel nausea. weakness
from 1 day before entering the hospital. Headache with
dizzy, feel burn in the chest area and spreading
backwards. and cough since 2 days ago. patients loss
the appetite since three days before entering the
hospital. Denied fever, but cold sweat. There’s no
complain about urinary track and defecation.
Past History Illness
 There is a history of DM for 10
years Allergic Findings
 Gangrene in his right foot Allergy of food, cold and
 History of trauma was denied medicine was denied
 History of surgery
 Asma (-)
Lifestyle History
Family History Illness
 His father had CHF and mother had • Patient difficult to eat, no
DM appetite,eat 1-2x a day,
Medication History small portions
 Patient said he’s consuming • Smoke : stop smoked for 7
metformin and glibenclamid but stop
months ago
1 month ago and now he is
consuming insulin • Alcohol: Denied
 Physical Examination
Generalis status
 General condition : Moderate ill
 Conciusness : composmentis
Vital signs
 Blood pressure : 120/70 mmHg
 Heart rate : 80 times/minute
 Respiratory rate : 20 times/minute
 Temperature : 36° C
 Anthropometry
• Weight before Sick : 71 kg
• Weight after Sick : 69 kg
• Height : 167 cm
• BMI : Overweight (pre-obesity)
 Status Generalisata
 General physical examination
 Head : normocephal, black hair, deformity (-)
 Face : symmetric
 Eyes : anemic conjungtiva (-/-),
icteric sclera (-/-), sunken eyes (-/-)
 Mouth : faring/tonsil hiperemis (-),
coated tongue (-), Moist mouth mucosa(+)
 Neck : normal JVP, no palpable mass,
lymphadenopathy (-), normal thyroid
 Thorax
Heart :
Pulmo :
I: normochest I: ictus cordis is not visible
P: ictus cordis is not palpable
P: vocal fremitus +/+
P:
P: sonor +/+
 Upper line  ICS 3 linea
A: vesicular sound.
breathing sounds ronki - parasternal dextra
/ -, wheezing - / -  Right Line  ICS 4 linea
parasternal dextra
 Left line  ICS 5 linea mid
clavicula sinistra
A: Regular heart sounds I & II,
gallops (-), murmur (-)
 ABDOMEN
 Inspection : Distended
 Auscultation : Bowel sounds (+)
 Palpation : pressure epigastric pain (+),
hepatomegali (+)
 Percussion : Timphani in all quadran abdomen

 EKSTREMITIES
Upper Lower
Akral warm warm
Oedema - / -
CRT < 2 detik / < 2 detik
Gangrene - +
 Resume
Patient came to RSIJ with Dyspnea since 1 day before
hospital admission. Dyspnea d’effort (+). vomiting one time. Before
vomiting patient feel nausea. weakness from 1 day before entering
the hospital. Headache with dizzy, feel burn in the chest area and
spreading backwards. and cough since 2 days ago. patients loss the
appetite since three days before entering the hospital. Denied fever,
but cold sweat. There’s no complain about urinary track and
defecation.
Blood pressure 120/70 mmHg, Heart rate: 80 times/minute,
Respiratory rate : 20 times/minute, Temperature : 36° C. There is not
abnormalities at physical examination.
At laboratory examination decrease haemoglobin, hematocrit,
eritrosit. And increased ureum, creatinin, leukosit
 05 June 2017 Result Unit Reference Methods
Hematologi
Routine
Hemoglobin 9,6 g/dL 13,2 – 17,3 SLS-Hemoglobin
Laboratory Finding 05 – June -
Leukosit 17,56 103/ɥL 3.80 – 10,60 Flow Cytometry
Hematokrit 30 % 40 - 52 CPHD Method
2017
Trombosit 313 103/ɥL 150 – 440 Flow Cytometry
Eritrosit 3,61 106/ɥL 4,40 – 5.90 Flow Cytometry
MCV/VER 82 fL 80 – 100 Calculation
MCH/HER 27 pg 26 – 34 Calculation
MCHC/KHER 32 g/dL 32 – 36 Calculation
Ureum blood 150 mg/dL 10 - 50 Urease – GLDH
Creatinin blood 3,4 mg/dL < 1.4 Jaffe Method
Natrium 138 mEq/L 135 – 147
Kalium 4,6 mEq/L 3,5 – 5,0
Clorida 105 mEq/L 94 – 111
Blood Glucose 338 Mg/dL
(23.00) Hexokinase
Problem List
Congestive Heart Failure (CHF)
Diabetic Mellitus
 Assessment
Congestive Heart Failure
 S: Patient’s complain about Dispneu and feel burn
in the chest area. Nausea and vomiting one time,
headache with dizzy and weakness
 O:
Vital sign
Blood pressure : 120/70 mmHg
Pulse : 80 times/ minute
Temperature : 36°c
Respiratory rate : 20 times/ minute
Physical Examination
Thorax
I: normochest
P: vocal fremitus +/+
P: sonor +/+
A: vesicular sound. breathing sounds ronki - / -, wheezing
-/-
Heart :
I: ictus cordis is not visible
P: ictus cordis is not palpable
P:
Upper line  ICS 3 linea parasternal dextra
Right Line  ICS 4 linea parasternal dextra
Left line  ICS 5 linea mid clavicula sinistra
A: Regular heart sounds I & II, gallops (-), murmur (-
)
 A:
Congestive Heart Failure (CHF)
 P:
Treatment plan:
Letonal 25 mg 1x1
Valsartan 80 mg 1x1
Aspilet 1x1
Ranitidin 1x1
Omz 1x1
Diabetic mellitus
 S: Patient had DM for 10 years, uncontrolled, and his mother
died because diabetic mellitus. History of insulin use (+)
 O:
Blood pressure : 120/70 mmHg
Heart rate : 80 times/minute
Respiratory rate : 20 times/minute
Temperature : 36° C
Amputation foot because diabetic complication
05/06/17 Glucose : 330 mg/dL
07/06/2017 Glucose : 338 mg/dL
 A: Diabetic mellitus
 P: Injection Insulin
Tanggal S O A P
07-06- Dispneu (+), BP: 120/90 Congestive Valsartan 800 mg
oral (sore) 1x1
2017 cold sweat (+), N: 86x/m Heart Failure Digoxin oral (siang)
headache (+), S: 36.30C 1x1
OMZ oral (2x1)
nausea (+), Rr: 22x/m Aspillet oral (1x1)
weakness (+), Glucose at Alprazolan oral extra

Anxious(+) 05.00: 309

loss the mg/dL
appetite (+), Glucose at
feel burn in 11.00: 106
chest area (+), mg/dL
cough (+) Glucose at
17.00: 162
mg/dL
Glucose at
23.00: 338
Tanggal S O A P
08 – 06 – Dispneu (+), BP: 120/80 Congestive Valsartan 800 mg
oral (sore) 1x1
2017 headache (+), mmHg Heart Failure Digoxin oral (siang)
loss the N: 82x/menit 1x1
OMZ oral (2x1)
appetite (+), Rr: 18x/menit Aspillet oral (1x1)
feel burn in S: 36,20 C Alprazolan oral extra

chest area (+),

Cough (+)
Tanggal S O A P
09 – 06 – Dispneu (+), BP: 120/80 Congestive Valsartan 800 mg
oral (sore) 1x1
2017 headache (+), mmHg Heart Failure Digoxin oral (siang)
loss the N: 73x/menit 1x1
OMZ oral (2x1)
appetite (+), Rr: 19x/menit Aspillet oral (1x1)
feel burn in T: 360 C Alprazolan oral extra

chest area (+),

Cough (+)
Tanggal S O A P
10 – 06 – Dispneu (+), BP: 110/80 Congestive Valsartan 800 mg
oral (sore) 1x1
2017 headache (+), mmHg Heart Failure Digoxin oral (siang)
loss the N: 86x/minute 1x1
OMZ oral (2x1)
appetite (+), Rr: Aspillet oral (1x1)
Anxious (+) 19x/minute Alprazolan oral extra

feel burn in T: 36,30 C

chest area (+)
 Definitions
 Congestive heart failure (CHF) is a complex
clinical syndrome that can result from any
functional or structural cardiac disorder that
impairs the ventricle’s ability to fill with or eject
blood.
Epidemiology
 The rate of CHF per person-year rose more than
10 times between the age of 29–39 years (0.6–0.8
cases/1000 years) and 70–74 years (8.7
cases/1000 years).
Etiologies
 Weakened heart muscle (cardiomyopathy)
 Damaged heart valves.
 Blocked blood vessels supplying the heart muscle
(coronary arteries), which may lead to a heart
attack (This is known as ischemic cardiomyopathy.
...
 Toxic exposures, such as alcohol or cocaine
Patomekanisme
Clinical symptoms
Treatment Pharmacology
 ACE-1 (Angiotensin – Converting enzym inhibitor)
 Digitalis, 3x0,25 mg 3 days, and then maintenance dose 1x0,25
mg
 Diuretik: Furosemide (1-2)x40 mg
 Decreased afterload:
-Captopril 2-3x6,25 – 12,5 mg/day
-Calsium Antagonis
 Increase contractility heart : Digoksin: loading dose 3x0,25 mg,
3 days
 Decreased preload
-Furosemide: 20-40 mg/day (minor case), 40-80 mg/day (mayor
case)
Treatment non Pharmacology
Decreased wok hard and rest
Diabetic Mellitus Type 2
 Diabetes is a group of metabolic diseases characterized by
hyperglycemia resulting from defects in insulin secretion,
insulin action, or both. The chronic hyperglycemia of diabetes
is associated with long-term damage, dysfunction, and failure
of differentorgans, especially the eyes, kidneys, nerves,
heart, and blood vessels.
Epidemiology
 Globally, an estimated 422 millions adults are living with
diabetes mellitus, according to the latest 2016 data from
WHO. Diabetes prevalence is increasin rapidly, previous
2013 estimates from the international Diabetes federation
put the number at 381 million people having diabetes. The
number is projected to almost double by 2030. type 2
diabetes makes up about 85-90% of all cases. Increases in
the overall diabetes prevalence rate largely reflect an
increase in risk factors for type 2, notably greater longevity
and being overweight or obese.
Etiology
 The etiology of type 2 diabetes mellitus appears to involve
complex interactions between environmental and genetic
factors. Presumably, the disease develops when a
diabetogenic lifestyle (ie, excessive caloric intake,
inadequate caloric expenditure, obesity) is superimposed on
a susceptible genotype.
Clinical symptoms
Increased thirst and frequent urination
Increased hunger
Weight loss.
Blurred vision.
Slow-healing sores or frequent infections.
Areas of darkened skin.
Risk Factor
Treatment
Changing lifestyle , diet which will leads to weight loss and a
significant improvement in blood sugar level, and aerobic
exercise which will lead to reduction in the HbA1C and
improved insulin sensitivity.
Medications:
Biguanide
Sulfonylureas
Non Sulfonylureas and other types.
Insulin injection may either be add to oral treatment or used
alone.
References
1. American Diabetes Association, Standards of Medical Care in
Diabetes 2017
2. http://emedicine.medscape.com/article/117853-overview#a4
3. World Health Organization, Global Report on Diabetes. Geneva,
2016. Accessed 30 August 2016.
4. Braunwald E. The war against heart failure; the Lancet lecture.
Lancet 2014;385:812–824.
5. Bartunek J, Vanderheyden M, Hill J, Terzic A. Cells as biologics
for cardiac repair in ischaemic heart failure. Heart 2010;96:792–
800.
THANK YOU 