ARRYTHMIA:

Atrial Fibrillation Rapid Ventricular Response

Congestive Heart Failure NYHA Fc. I-II

Case report by:

Juwita Valen Ramadhania
I4061171009

Preceptor:
Letkol (CKM) dr. Prihati Pujowaskito, Sp. JP (K), MMRS
Cardiology Department Dustira District Hospital
Faculty of Medicine Tanjungpura University
2018
Anamnesis (Autoanamnesis)

 Mrs. T/ 59 y.o/ Ceremai Ward

 Chief Complaint: Shortness of Breath (SOB)
 Patient admitted that she often gets intermittent SOB in the
last 3 weeks and get worsen in the last 2 days.
 SOB occurs especially when she doing an activity (eg: cleaning
her house) and decreasing during rest. SOB usually occurs ± 1
hour. Patient use a pillow when she is spleeing.
 The patient admitted there were no complaints of chest pain,
palpitations, dizziness, decreased consciousness, weight loss,
bowel and urinary complaints.
Anamnesis (Autoanamnesis)

 Patient said that she has hypertension disease and take 5mg of
Amlodipine everyday in the last 1 year.
 She has relatives that suffer cardiovascular disease.
Physical Examination
BP = 110/80 mmHg PR = 128 bpm, irregular, RR = 26 tpm T = 36.5 celcius
pulsus deficit SpO2 = 82%
General appearance looked moderately ill GCS E4 V5 M6 ; VAS Score : 0

Head Anemic (-) Icteric (-)

Neck JVP 5+3 cmH2O

Thorax Retraction (-), Ictus Cordis not seen.

Cor S1 S2 single, mur mur (-), gallop (-) extrasystole (-)

Pulmo Simetric, SF D = S Rh +/+ Wh - /-

Abdomen Convex, Soefl, Hepar : Liver span 11 cm, spleen traube space tympani.
Tenderness (-)

Extremities Pitting oedem of lower extremities (+/+)

Laboratorium Findings
July 3rd 2018

Hemoglobin : 12.3 g/dl RBS : 109 mg/dl

Eritrosit : 4.2 x 106/µl Sodium : 148 mmol / L
Leukosit : 7.200/µl Potassium : 4.10 mmol / L
Hematokrit : 36,7% Chloride : 108 mmol / L
Trombosit : 289.000/µl Ureum : 35 mg / dl
MCV : 87,2 fl Creatinin : 0.9 mg / dl
MCH : 29,2 pg Triglycerides : 42 mg / dl
MCHC : 33,5 g/dl LDL Cholesterol : 124 mg / dl
RDW : 13,1 %
Ba/Eo/Sg/Li/M :
0,7/4,3/60,1/26,3/8,6 %
ECG
July 30rd 2018
In the ER:
ECG
 Rhythm : Arrhythmia
 Frequency : 120-200 bpm
 Frontal Axis : Normoaxis
 Horizontal Axis : Normoaxis
 P wave : Normal P wave disappeared and
replaced by fibrillation waves
 P-R interval : Can not be calculated
 Q Wave : Normal
 QRS complex : 0.08 s
 R-R Interval : Irregular
 ST segment : Normal
 T wave : Normal
Conclusion : AF RVR HR 120-200 bpm
ECG
July 30rd 2018
30-7-2018 06.30

30-7-2018 12.10
ECG
July 30rd 2018
30-7-2018 12.10

30-7-2018 16.10
ECG
30-7-2018 22.10

31-7-2018 08.00
Thorax X-Ray
Conclusion: Cardiomegaly
SCORING
 Framingham criteria:
 Mayor criteria : neck vein distention, rales, and cardiomegaly.
 Minor Criteria : dyspnea on ordinary exertion, bilateral
ankle oedema and tachycardia.
 NYHA Fc I-II
 CHA2DS2-VASc: 3
Diagnosis
Clinical Diagnosis
AF RVR

Anatomical Diagnosis
AV Node

Etiologic diagnosis
Non-atherosclerotic

Additional diagnosis
1. CHF NYHA Fc I-II
2. HT Controlled
3. Dyslipidemia
Therapy

ER
 Non medical:
 Semi fowler position
 Medical:
 Oxygen 8 Lpm
 NaCl 500 cc/24 hours
 Furosemide 1x20mg (iv)
 Amiodaron 1x150mg for 10min, then 1mg/min for
6h
 Warfarin 1x2mg (Po)
Therapy
Ward
 Non-Medical:
 Take control of risk factors
 Serial ECG per 4-6 hours
 Medical:
 Furosemide 3x20mg (iv)
 Digoxin 1x0.25mg (iv), maintenance 0.125-0.25mg
 Warfarin 1x2mg (po)
 Ramipril 1x5mg (po)
 Atorvastatin calcium 1x20mg po (night)
Therapy
Post hospitalized
 Non-Medical:
 Take control of risk factors
 INR test after 7 days consuming warfarin
 Medical:
 Warfarin 1x2mg (po)
 Ramipril 1x5mg (po)
 Bisoprolol 1x2,5mg (po)
 Atorvastatin calcium 1x20mg (po: night)
Prognosis
 Quo ad vitam : dubia ad bonam
 Quo ad sanactionam : dubia ad bonam
 Quo ad functionam : dubia ad bonam
Thank you