Congestive

Heart Failure
Disusun oleh:
Muhammad Alkadri Anugrah
030.14.126

Pembimbing:
dr. Arif Gunawan., Sp.PD, MARS
Patient’s Identity
Name : Ny. Mulyati
No. RM : 00.76.95.04
Gender : Female
Age : 48 years 11 months 14 days
Date of birth : Karawang, 20 Mei 1970
Address : Dusun Ciagem RT014 RW 003
Religion : Islam
Ethnic : Sundanese
Job : IRT
Education : Elementary school
Marriage : Married
Contoso
Date of entry : Mei 03, 2019 from IGD RSUD karawang Pharmaceuticals
 Anamnesis
• Keluhan utama
Pasien datang ke IGD Rsud Karawang
dengan keluhan sesak napas sejak 5
hari SMRS.
• Keluhan tambahan
Keluhan sesak dirasakan saat
beraktivitas. Pasien mengaku tidur
dengan 3 bantal, pasien juga sering
terbangun dimalam hari karena sesak.
Keluhan seperti demam, batuk, mual,
muntah, nyeri dada disangkal oleh
pasien. BAK dan BAB tidak ada
keluhan
• Riwayat penyakit sekarang
Pasien mengeluh sesak sejak 5 hari
SMRS. Sesak napas memberat pada saat
aktivitas dan sesak akan berkurang ketika
duduk istirahat. Pasien juga mengeluh
cepat merasakan lelah bila melakukan
aktivitas seperti berjalan dan menaiki
tangga, berdebar-debar, kaki bengkak
dan bila tidur harus menggunakan 3
bantal. Tidak ada nyeri dada, demam,
batuk, mual dan muntah. BAB dan BAK
tidak ada keluhan.
• Riwayat penyakit dahulu
Pasien belum pernah mengalami keluhan Contoso
Pharmaceuticals
page 3
yang sama sebelumnya, Hipertensi (+),
• Family History
The patient's father has a history
of heart disease

• Treatment History
Patients do not routinely control
the doctor beforehand.

• Habit History
Eating habits are not maintained,
rarely exercise, not drink alcohol Contoso
and not smoke Pharmaceuticals
 Physical examination
• General state of consciousness: Compos
Mentis
• Impression of pain: Looks sick medium

Vital signs
• Blood pressure : 140/90 mmHg
• Pulse : 70 x / minute
• Respiration : 36 x / minute
• Temperature : 36.5 ° C
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• SpO2 : 98% Pharmaceuticals
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• Head : Normosefal
• Eyes : Isocorous pupils, anemic
conjunctiva - / -, sklera jaundice - / -
• Ears : Deformity (-), hyperemia
(-), edema (-), cerumen (-), tragus
tenderness (-), tonsile pain (-)
• Nose : Deformity (-), septal
deviation (-), secretion (-), nasal
lobe breathing (-)
• Throat : Uvula in the middle,
symmetrical pharynx, T1 / T1,
hyperemic (-)
• Mouth : Cyanosis (-), dry mouth (-),
bleeding gums (-), hyperemic gums
(-), not dirty tongue, dental plaque
(-)
Neck
• There is no KGB enlargement
Thorax:
• Inspection: symmetrical (+) chest shape,
symmetrical chest wall movement, intercostal
retraction (-), widening ribs (-), skin
abnormalities (-),
• Palpation: symmetrical chest wall motion,
tenderness (-), lump (-), vocal fremitus not
weakened or increased in both front and rear
lung fields
• Percussion: sonor +/+
• Auscultation: Vesiculate breath sounds + / +,
ronkhi - / -, wheezing + / +
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Heart:
• Inspection: the pulse of ictus cordis
is not visible
• Palpation: thrill (-), ictus cordis is
not palpable
• Percussion: the left border of the
heart in the VI ribs in the left
anterior axillary line, the right
border of the heart at the IV ribs
medially from the right
midclavicular line.
• Auscultation: regular heart I and II
sounds, gallop (-), murmurs (-)

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Pharmaceuticals
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 Abdomen
• Inspection: Normal shape,
symmetrical wall motion
• Auscultation: bowel sounds (+)
2-3x / minute, arterial bruit (-)
• Palpation: palpable supple,
mass (-), tender (-), murphy’s
sign (-), Ballotement (-) loose
pain (-), spleen and liver
enlargement (-)
• Percussion: shifting dullness (-)
Ekstremitas
• Upper extremities
Right and left symmetrical,
deformity - / -, CRT <2 seconds,
warm akral + / +, oedem - / -
• Lower extremities
Right and left symmetrical,
deformity - / -, CRT <2 seconds, Contoso
Pharmaceuticals
warm akral + / +, oedem +/ + page 8
Laboratory examination

Authorize Monetize
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varius.

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Pharmaceuticals
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Rontgen thoraks

ECG

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Diagnosis
Working Diagnosis:
CHF
Differential Diagnosis :
Gagal jantung akut
PJK

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 Therapy
• IVFD Nacl 0,9% 8 tpm
• Inj furosemid 2x1 amp
• ISDN 3x10 mg
• Captopril 3x12,5 mg
• Aspilet 1x80 mg

PROGNOSIS
Ad vitam : dubia ad bonam
Ad functionam : dubia ad bonam
Ad sanationam : dubia ad bonam
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Followup day 1
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 Follow up day 2

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Follow up day 3 Contoso
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Follow up day 4

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 Conclussion
Mrs. M, 48 years came to the emergency room
RSUD Karawang with complaints of shortness of
breath since 5 days of SMRS. Shortness of breath
during activity and tightness will decrease when
sitting resting. Patients also complain of feeling
tired when doing activities such as walking and
climbing stairs, palpitations, swollen feet and when
sleeping, they should use 3 pillows. There is no
chest pain, fever, cough, nausea and vomiting. BAB
and BAK no complaints. Patients have never
experienced the same complaint before, patients
have a history of hypertension but rarely control
and do not routinely take medication, DM (-),
kidney disease (-), heart disease (-) lung disease (-).
The patient's father has a history of heart disease.
Patients have never smoked and consumed
Basic diagnosis
History is found:
• Shortness of breath since 5 days of SMRS
• Ortopneu
• Activity tolerance decreases
• Get tired quickly
• Palpitations
• Patients have a history of hypertension but
do not routinely take medication
• The patient's father has a history of heart
disease
physical examination
• Blood pressure: 140/90 mmHg
• Respiration: 36 x / minute
• increase in JVP (5 + 4)
• inferior extremity edema
• Rhonki + / + Contoso
Pharmaceuticals
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Exploration Plan
for patients
• Analisa gas darah
• Cek elektrolit
• Echo
• Rontgen thoraks
• Edukasi pasien

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Pharmaceuticals
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THANKYOU,Next  Contoso
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