CONGESTIVE HEART FAILURE

OKTAVIANI HALIM 030.09.178

PATIENT IDENTITY
Name Age Sex Address Religion Ethnic Marital status : Mr. Edi Sunardi : 55 years old : Man : Teluk jambe, Karawang : Moeslem : Sundanese : Marriage

Education
Occupation Addmited

: Senior High school

: Employe : August 1th, 2013

PRESENT ILLNESS
Main Complaint
Shortness of breath since 3 days before admission

Additional Complaint

Pain in the upper middle stomach, fatigue, dizzy, nausea, vomiting, fever, deterioration of visual acuity.

MAIN COMPLAINT
Shortness of breath since 3 days before admission, continuously, affected by activities and position, sleep with 3 pillows, sudden awakening in the night.

ADDITIONAL COMPLAINT
Pain in the upper middle stomach since 3 days before admission,dull, continuously. Fatigue is present even at rest since 3 days before admission. Dizzines since 3 days before admission Nausea since 1 week ago, intermittently, affected by drinking and eating Vomiting since 3 days before admission, intermittently, yellow, food in the vomit content, no blood and no mucus. Fever 3 days before admission.

ADDITIONAL COMPLAINT

Deterioration of visual acuity since 3 weeks before admission Excessive thirst Excessive hunger Increased urination

PAST MEDICAL RECORD

Similar illness before (-) Hypertensi on(-)

Diabetes (+)

Pleural efusion (+)

Amputation (+)

Kidney disease (-)

HISTORY OF THE DISEASE

3 days ago on admission 1 year Deterioration of visual acuity Shortness of breath Pain in the upper middle stomach fatigue Nause Vomiting Dizzy Classical sign of diabetes

Uncontroled diabetic mellitus

Gangren pedis sinistra Amputation

15 years ago

3 weeks

FAMILY HISTORY
Similar illness (-) Diabetes (+)

Lung disease (-)

Alergic (-)

Hypertensi on(-)

Heart disease (-)

HABITS HISTORY
Alcohol consumption (-) Smoking (-) Routine Excercise (-) Tattoos (-) Blood Transfusion (-)

PHYSICAL EXAMINATION
General appearance
Conciousness Nutrition status

Moderately ill Compos mentis

Good

VITAL SIGN
BP: 110/60 mmHg HR: 48x/m

RR: 40x/m

T: 36,5 C

PHYSICAL EXAMINATION
Head
Normocephali

Eyes
ANEMIC CONJUNCTIVA +/+, Icteric sclera -/ Pupils are equal, round, diameters 3mm, reactive to light.

Mouth
Lip: cyanosis(-) dryness (-) Pharynx: hyperemic (-), symmetrical, uvula at midline Thypoid tounge -

Neck
Lymph gland & Thyroid gland is not palpable, normal JVP.

THORAX - HEART
INSPECTION Ictus cordis is not visible. Ictus cordis is palpable at 2 cm lateral 5th ICS LMCS

PALPATION

PERCUSSION

Enlargement of the heart

AUSCULTATION

Regular I - II heart sound, no murmur and gallop

THORAX - PULMO
INSPECTION
Symmetrical Normal vocal fremitus , equal vocal resonance

PALPATION

PERCUSSION

Sonor in both lung

AUSCULTATION

Ronchi -/-, wheezing -/-

ABDOMEN
Inspection: Brown skin Swelling symmetric (-) Caput medusa (-) smiling umbilicus (-) Palpation: Supple (+) Tenderness () Distension (-) Undulation () Defense muscular (-), mass (-) No enlargement of liver and spleen Percussion: No pain present on abdominal percussion Tympanic Shifting dullness (-) CVA (-) Auscultation: Bowel sound (+) Arterial bruit (-) Venous hum (-)

EXTREMITY EXAMINATION
Warm acrals

+ + + - - -

Edema

LABORATORY TEST
August 1st , 2013
Examination
Hb Ht

Result
12,2 g/dL 34 %

Normal Range
12-17 g/dL 37-58 %

Leucocytes Thrombocytes
Blood glucose Ureum Creatinine

18.740 /L 222.000/L
604 90,8 1,42

5000-10000 150.000-450.000
80-140 10-45 0,4-1,5

LABORATORY TEST
August 1st , 2013 CK-MB
Troponin T

33 U/l
1,8

<24 u/l
<0,01mg/l

LABORATORY TEST
August 3th , 2013
Blood glucose (fasting) Blood Glucose (2 hours Post prandial) 322 70-100

182

<140

THORAX
THORAX PA CTR > 50%

ECG

ECG

DIFFERENTIAL DIAGNOSIS

CAVB

Deterioration of visual acuity

PND,
Radiographic cardiomegally, DOE.
Classical sign of DM,random Blood glucose: 604, fasting blood glucose: 322.

Fatigue at rest.

CHF ec NSTEMI, CAVB, DM TYPE II, RETINOPATHY DIABETIC

SUGESTED EXAMINATION
REPEAT ED BLOOD TEST

ECHOCA RDIOGR APHY

ANGIOG RAPHY

REPEATED ECG

THERAPHY (EMERGENCY ROOM)

O2 NaCl 0,9% 1 kolf/24 hours Dobutamin 3 micro drip Lovenox 2x0,6cc T.Aspilet 1x1 Clopidogrel 1x5 Simvastatin 1x20

FOLLOW UP AUGUST 2RD 2013

S : Shortness of breath, Chest pain, nausea 0 : bp: 140/80 mmhg hr: 71bpm rr: 42bpm T: 36,5C O2 saturation : 95-97

NaCl 0,9% 1 kolf/24 hours Furosemid V Cedocard 9 mg/l Lovenox 2x0,6 cc (I) Captopril 3x12,5 ISDN 3x5mg Clopidogrel 1x1 Simvastatin 1x20g Omeprazole 2x1 ampl

THERAPHY

PROGNOSIS

AD VITAM

: DUBIA AD BONAM

AD FUNCTIONAM : DUBIA AD MALAM

AD SANATIONAM : DUBIA AD MALAM

LITERATURE REVIEW

ACUTE MYOCARDIAL INFARCTION

DEFINITION

Myocardial infarction (MI; ie, heart attack) is the irreversible necrosis of heart muscle secondary to prolonged ischemia

SYMPTOMS
Pressure, tightness, pain, or a squeezing or aching sensation in your chest or arms that may spread to your neck, jaw or back) A feeling of fullness, nausea, indigestion, heartburn or abdominal pain Shortness of breath Sweating or a cold sweat Feelings of anxiety or an impending sense of doom Fatigue Trouble sleeping Lightheadedness or dizziness

SPECIAL CONDITION

The patient may recall only an episode of indigestion as an indication of myocardial infarction. In some cases, patients do not recognize chest pain, possibly because they have a stoic outlook, have an unusually high pain threshold, have a disorder that impairs function of the nervous system and that results in a defective anginal warning system (eg, diabetes mellitus), or have obtundation caused by medication or impaired cerebral perfusion. Elderly patients with preexisting altered mental status or dementia may have no recollection of recent symptoms and may have no complaints whatsoever.

Coronary artery disease

Narrowed coronary artery

Build-up plaque in coronary artery

Rupture of the plaque

A blood clot forms at the site of the rupture

Complete/partial blocked in coronary artery

Spill out cholesterol and other substances into the bloodstream

Myocardial infarction

RISK FACTORS
Age Tobacco High blood pressure High blood cholestrol or tg levels Diabetes Family history of heart attact Lack of phisycal activities Obesity Stress Illegal drus use

TEST AND DIAGNOSIS

ECG BIOMARKER (TROPONIN T & CK-MB) THORAX X-RAY ECHOCARDIOGRAPHY CORONARY CATHETERIZATION EXCESSIVE STRESS TEST

PHYSICAL EXAMINATION

Acute Coronary Syndromes Algorithm

Out-of-Hospital Care
Decision 1: Does the patient have chest discomfort suggestive of ischemia? Assess and care for the patient using the primary and secondary surveys.

Prepare patient for hospital admission. Monitor and support ABCs (airway, breathing, and circulation). Take vital signs. Monitor rhythm. Be prepared to administer CPR if the need arises. Watch for it. Use a defibrillator if necessary. Think MONA: Administer oxygen, aspirin, nitroglycerin, and morphine, if needed. If possible, obtain a 12-lead ECG. Interpret or request an interpretation of the ECG.If ST elevation is present, transmit the results to the receiving hospital. Hospital personnel gather resources to respond to STEMI. Start filling out a fibrinolytic checklist.

Acute Coronary Syndromes Algorithm

In-Hospital Care

Within the first 10 minutes that the patient is in the Emergency Department (ED), work through the following: Check vital signs. Evaluate oxygen saturation. Establish IV access. Get or review a 12-lead ECG. Look for risk factors for ACS, cardiac history, signs and symptoms of heart failure by taking a brief, targeted history. Perform a physical exam. Complete a fibrinolytic checklist and check contraindication Obtain a portable x-ray (less than 30 minutes).

Acute Coronary Syndromes Algorithm

Begin general treatment in the ED: Start oxygen at 4 L/min and maintain oxygen saturation > 90%. If the patient did not take aspirin while with the EMS provider, give aspirin (160 to 325 mg). Administer nitroglycerin, either sublingual, spray, or IV. Give the patient morphine (IV) if pain is not relieved by nitroglycerin.

Acute Coronary Syndromes Algorithm

If the patient is classified with NSTEMI or high-risk unstable angina, follow this section of the algorithm. Start adjunctive treatments for NSTEMI, as indicated: Nitroglycerin Beta-adrenergic receptor blocker Clopidogrel Heparin (UFH or LMWH) Glycoprotein IIb/IIIa inhibitor

Acute Coronary Syndromes Algorithm

ECG shows normal ECG or nonspecific ST-T wave changes Consider admitting the patient to hospital or to a monitored bed in ED Monitor ECG continually for changes in ST-T. Obtain serial cardiac markers, including troponin. Consider stress test.

CONGESTIVE HEART FAILURE

DEFINITION

Heart failure develops when the heart, via an abnormality of cardiac function (detectable or not), fails to pump blood at a rate commensurate with the requirements of the metabolizing tissues or is able to do so only with an elevated diastolic filling pressure.

HISTORY TAKING
Exertional dyspnea Orthopnea Paroxysmal nocturnal dyspnea Dyspnea at rest Pulmonary edema Chest pain/pressure and palpitations Fatigue and weakness Nocturia and oliguria Cerebral symptoms

Framingham major criteria

Paroxysmal nocturnal dyspnea Weight loss of 4.5 kg in 5 days in response to treatment Neck vein distention Rales Acute pulmonary edema Hepatojugular reflux S3 gallop Central venous pressure greater than 16 cm water Circulation time of 25 seconds Radiographic cardiomegaly Pulmonary edema, visceral congestion, or cardiomegaly at autopsy

Framingham minor criteria

Nocturnal cough Dyspnea on ordinary exertion A decrease in vital capacity by one third the maximal value recorded Pleural effusion Tachycardia (rate of 120 bpm) Bilateral ankle edema

The New York Heart Association (NYHA) classification system categorizes heart failure on a scale of I to IV,[4] as follows:
Class I: No limitation of physical activity Class II: Slight limitation of physical activity Class III: Marked limitation of physical activity Class IV: Symptoms occur even at rest; discomfort with any physical activity

PATHOPHYSIOLOGY
CORONARY ARTERY DISEASE HEART ATTACT

HYPERTE NSION

FAULTY HEART FALVE

DIABETES MELLITUS

EXTRA WORK FOR HEART MUSCLE

OTHER DISEASES WEEKENING HEARTS PUMPING ABILITY

CONGENITAL HEART DISEASE

HEART FAILURE

KILLIP CLASS
Killip class I includes individuals with no clinical signs of heart failure Killip class II includes individuals with rales or crackles in the lungs, an S3, and elevated jugular venous pressure. Killip class III describes individuals with frank acute pulmonary edema. Killip class IV describes individuals in cardiogenic shock or hypotensioN (measured as systolic blood pressure lower than 90 mmHg), and evidence of peripheral vasoconstriction (oliguria,cyanosis or sweating).

Killip class I:81/250 patients;32% (27 38%).Mortality rate was found to be 6%.(current 30 day mortality 2.8) Killip class II:96/250 patients;38% (32 44%).Mortality rate was found to be 17%.(current 30 day mortality 8.8) Killip class III:26/250 patients;10% (6.6 14%).Mortality rate was found to be 38%.(current 30 day mortality 14.4)
Killip class IV:47/250 patients;19% (14 24%).Mortality rate was found to be 67%.

Theraphy

O2 Ventilasi non invasive Morphin & analog morphin Loop diuretika Vasodilator Nitrat Obat-obat inotropik

DIABETES MELLITUS

KRITERIA DIAGNOSIS DM
1 2 3 Gejala klasik DM + GDS 200mg/dl Atau Gejala klasik DM + GDP 126mg/dl Atau Kadar Glukosa darah 2 jam pada TTGO 200mg/dl

KOMPLIKASI KRONIK DM

MIKROVASKULAR:
GINJAL RETINA MATA

MAKROVASKULAR:
JANTUNG KORONER PEMBULUH DARAH KAKI PEMBULUH DARAH OTAK

NEUROPATI :
MIKRO DAN MAKROVASKULAR

RENTAN INFEKSI :
MIKRO DAN MAKROVASKULAR

PRINSIP PENATALAKSANAAN DM

OBAT HIPERGLIKEMIK ORAL

INSULIN

OBAT HIPERGLIKEMIK ORAL

PEMICU SEKRESI INSULIN PENAMBAH SENSITIVITAS TERHADAP INSULIN PENGHAMBAT ALFA GLUKOSIDASE

GOLONGAN INKRETIN

PEMICU SEKRESI INSULIN

GOLONGAN SULFONILUREA Khlorpropamid Glibenklamid Gliklasid Glikuidon Glipsid Glimepirid
GOLONGAN GLINID REPAGLINID NATEGLINID

Penambah sensitivitas terhadap insulin

Biguanid
Thiazolindion

LAIN-LAIN

PENGHAMBAT ALFA GLUKOSIDASE/ACARBOSE

GOLONGAN INKRETIN
INKRETIN MIMETIK PENGHAMBAT DPP IV

TERAPI INSULIN
Indikasi: Dm tipe 1

Dm tipe 2 bila:
Pengobatan oral tidak mencapai target Keadaan stres berat, sperti pada infeksi berat, tindakan pembedahan, infark miokard akut atau stroke Dm gestasional KAD HHS

Dm yang membutuhkan suplemen tiggi kalori

Gangguan fungsi ginjal atau hati yang berat KI/alergi obat oral

KARAKTERISTIK INSULIN YANG ADA DI INDONESIA

CEPAT
Novorapid, apidra, humalog

SINGKAT
Actrapid, humulin-R

MENENGAH
Insulatard Humulin N

KARAKTERISTIK INSULIN YANG ADA DI INDONESIA

CAMPURAN
Mixtard 30, Humulin 30/70, Novomix 30\

BASAL
Lantus, levemir

THANK YOU