Skenario Mrs. Cikya

Mrs. Cik Ya, 49 years woman, admited to hospital with the main chief complaint shortness of breath since yesterday. 2 months ago, patient felt edema on her leg, palpitation. She went to clinic, and got medicine without any further physical examination. Fortunately the symptoms relief. Since a month ago, she often felt fatigue and nausea. And one week ago she felt very tired and slept with 2 pillows, fever, cough, nausea and epigastric pain. Then she visited the same doctor but she just accepted drugs for gastric complaint and amoxicilin tab 3x500mg, ambroxol sirup 3xc and paracetamol 3x1 tab/day, pc.Previous history: Recurrent pharyngitis (+), asymetric and migratory arthritis of knee and ankle joint (+), family history of CAD (+). Menopause since 2 years ago.

Physical exam:Orthopnoe, Ht 155 cm, Bw 70 kg, BP 110/70 mmHg, PR 115 bpm, irregular.RR 36x/m. Temperature 38,5 degree celcius.JVP 5+2, basal rales (+), wheezing (+).Heart: HR 128x/m, arythmic, left border 2 finger lateral LMC sinistra ICS V.Liver palpable 3 fingers below arcus costae and ankle edema.

Labor:Hb 12,2g%, WBC 15.000, Trombosit 250.000, Diff count: 1/1/3/70/30/2Total cholesterol 260 mg%, triglyceride 240mg%.Blood glucose 105 mg%. Glucose urine (-).SGOT 52U/L, SGPT 43 U/L, Total bilirubin 1,8 mg/dl, Ureum 40 mg/dl, creatinin 1,1 mg/dl, sodium 135 mmol/l, potasium 4 mmol/l.CK NAC 140 U/L, CK MB 25 U/L, Troponin 0,1 ng.

Chest X-ray:

CTR >50%, signs of chepalization.

ECG:

AF Rapid ventricular respons, left axis, 130 x/m, left atrial hiperthrofi, RAH, RVH, LV Strain.

Echo:

Wall motion normal, MS severe, vegetasi (+), MR mild, AR moderate, TR moderate, PH moderate, PR mild, ejection fraction 55% and thrombus attached to LA, efusi pericard minimal.

I. TERM CLARIFICATIONa. Shortness of breath b. Edema c. Palpitation d. Fatique e. Nausea f. Fever g. Cough h. Epigastric pain i. Amoxicillin

j. Ambroxol k. Paracetamol l. Pharyngitis m. Asymetric Arthritis n. Migratory Arthritis o. Orthopnoe p. Cephalization q. Basal Rales r. Arythmic s. SGOT t. SGPT u. CK NAC v. CK MB w. AF rapid venticular x. Left axis y. Vegetasi (+) z. PH Moderate aa. Thrombus bb. Efusi Pericard

II. PROBLEM IDENTIFICATIONa. Mrs Cik Ya, 49 year old women is complain shortness of breath since yesterdayb. 2 months ago, patient felt edema on his leg, palpitation and got medicine without any

further physical examinationc. Since a month ago, she often felt fatique and nausead. one weeks ago she felt very tired and slept 2 pillows, fever, cough, nausea, and

epigastric paine. she visited the same doctor but she accepted drug for gastric complaint and amoxicillin

tab 3 x 500 mg, ambroxol sirup 3xc and paracetamol 3 x 1 tab/day, pc.f. Previous history : Recurrent pharyngitis (+), Asymetric and migratory arthritis of knee

and ankle joint (+), family history of CAD (+). Menopause since 2 years agog. Physical exam:

Orthopnoe, Ht 155 cm, Bw 70 kg, BP 110/70 mmHg, PR 115 bpm, irregular.RR 36x/m. Temperature 38,5 degree celcius.JVP 5+2, basal rales (+), wheezing (+).Heart: HR 128x/m, arythmic, left border 2 finger lateral LMC sinistra ICS V.Liver palpable 3 fingers below arcus costae and ankle edema.

h. Labor: Hb 12,2g%, WBC 15.000, Trombosit 250.000, Diff count: 1/1/3/70/30/2Total cholesterol 260 mg%, triglyceride 240mg%.Blood glucose 105 mg%. Glucose urine (-).SGOT 52U/L, SGPT 43 U/L, Total bilirubin 1,8 mg/dl, Ureum 40 mg/dl, creatinin 1,1 mg/dl, sodium 135 mmol/l, potasium 4 mmol/l.CK NAC 140 U/L, CK MB 25 U/L, Troponin 0,1 ng.

i. Chest X-ray: CTR >50%, signs of chepalization. ECG : AF rapid ventricular Respon, Left axis, 130x/mnt, LAH, RAH, RVH, LV strain Echo: Wall motion normal, MS

severe, vegetasi (+), MR mild, AR moderate, TR moderate, PH moderate, PR mild, ejection fraction 55% and thrombus attached to LA, efusi pericard minimal.

III. PROBLEM ANALYSISa. Is there any correllation between her age, gender, and her condition? b. What is the cause of shortness of breath? c. What is mechanism shortness of breath? d. What cause & mechanism of edema on his leg, palpitation? e. What cause & mechanism of fatique and nausea?f. What cause & mechanism tired, fever, cough &epigastric pain?g. Why she need two pillow for her sleep?h. What cause and mechanism recurrent pharyngitis, asymetric, and migratory arthritis of

knee and ankle knee?i. What is cause and mechanism of menopause?j. What is the correlation between her previous history and her condition?k. What is the pharmacokinetics of the drugs?l. What is the effect and side effect of the drugs?m. Interaction between the drugs?n. What is the etiologi of CAD?o. Is there any possibility that CAD can be inherited?p. What is the correlation between her family history and his condition now? q. What is the interpretation & mechanism of keadaan umum? r. What is the interpretation & mechanism of vital sign?s. What is the interpretation & mechanism of pemeriksaan khusus?t. What is the correlation between her physical exam and his condition? u. What is the interpretation and mechanism of lab test? v. What is the interpretation and mechanism of radiology?w. What is the interpretation and mechanism of ECG ?x. What is the interpretation and mechanism of Echo?y. What is the correlation between her condition with her lab test?z. What is the correlation between her condition with radiology?aa. What is the correlation between her condition with ECG ?bb. What is the correlation between her condition with Echo? cc. What is the DD? dd. What is the Additional test?ee. What is the WD?ff. What is the Patofisiology?gg. What is the Management? hh. What is the Complication?ii. What is the Prognosis?jj. What is the KDU?

IV. HYPOTHESISMrs Cik Ya, 49 years old suffered from Congestive heart disease due to reumatic heart disease

V. SYNTHESISA. Anatomi dari Jantung

Jantung terdiri dari 3 lapisan jaringan yaitu:- Perikardium, terdiri dari 2 kantung yang luar yaitu jaringan fibrosa dan yang dalam

yaitu membrane serosa- Myokardium, terdiri dari otot jantung yang hanya ditemukan di jantung. Masing-

masing serat (sel otot) terdiri dari satu nucleus dan satu atau lebih cabang.- Endokardium, membatasi miokardium dan katum jantung. Terdiri dari sel epitel

selapis.

B. Index Massa Tubuh (IMT) CikYa

BMI=BB

(TB)2=70(1,55)2=29,13

CikYaObese I

C. Mekanisme Sign dan Symptom-Shortness of breath (dypsnea)

Gagal JantungBendungan

paru(Hipertensi pulmonal)

Refleks bronkokonstriksi(fase akut)

Volum vaskular pulmonalCairan interstitial paruEdema paru

Ventilasi paruRestrictive work(Frictional Resistance)

Kapasitas total paruLung compliance <<<Resistensi elastik

dispnea

BMI (Body mass index)

BMI = kg/m2

A BMI less than 18.5 is underweight

A BMI of 18.5–22.9 is normal weight

A BMI of 23.0 or higher is overweight

A BMI of 23.0–24.9 is at risk

A BMI of 25.0-29.9 is obese I

A BMI of 30.0 or higher is obese II

WHO WPR/IASO/IOTF in The Asia-Pacific Perspective: Redefining obesity and it’s treatment

-Oedem in legCHF EDV, Tek.pengisian, HR,

kontraktilitas miokardium

Pusat vasomotor

CO, BP ↓

Baroreseptor

Konstriksi arteri danvena

↓ Aliran plasma & perfusidarah ginjal Renin & Angiotensinogen Angiotensin I & II

otakMasukan air

Adrenal korteks

↓Retensi H2O & Na Aldosteron

↑ Cairan intra-ekstravaskuler

P.Hidrostatik kapiler ↑

Ketidakseimbangan vol.cairandan tekanan

edema

CHF EDV, Tek.pengisian, HR, kontraktilitas miokardium

Pusat vasomotor

CO, BP ↓

Baroreseptor

Konstriksi arteri danvena

↓ Aliran plasma & perfusidarah ginjal Renin & Angiotensinogen Angiotensin I & II

otakMasukan air

Adrenal korteks

↓Retensi H2O & Na Aldosteron

↑ Cairan intra-ekstravaskuler

P.Hidrostatik kapiler ↑

Ketidakseimbangan vol.cairandan tekanan

edema

-Fatigue

-Nausea

-hubungan sign dan symptom

D. Obat yang digunakan oleh Mrs. Cikya sebelumnya:There are four medicines that the doctor use, they are: 1. Amoxicillin Mechanism of action Inhibit the synthesis of bacteria cell wall Half life 1.6 hours Absorption good in intestine, stabile in acid condition, the absorption is same

when take before and after meal. Excrete in urine Doses 3x250-500mg Side effect : 1. GI disturbance 2. Hypersensitive 3. Serum sickness Contraindication renal disorder 2. Paracetamol Mechanism of action inhibit the synthesis and work of prostaglandin Half life 2-3 hours Absorption Good blank stomachs, metabolized by liver microsomal enzyme become sulfate and gluconoride. Excrete in urine Doses 3-4x325-500mg Side effect : 1. Hepatotoxic 2. Liver necrosis Contraindication renal disorder 3. Drugs for gastric complain Include: antacids, stomach anti secretion, and mucosal protective Mechanism of action: React with HCl in stomach to make salt and water (neutralization) Inhibit histamine release by blocking H2 receptors Inhibit proton pump (H+/K+ ATP-ase) Side effect: Change of colon habit Kation over absorption Systemic Alkalosis Contraindication: Renal disorder CHF ( if use high doses of NaHCO3) 4. Ambroxol Mechanism of action enhance mucolytic by altering molecular of mucous Side effect mild GI disturbance Contraindication gastric ulcer, 1st trimester of pregnancy What is the correlation between all of the symptoms? (2 months ago yesterday)

E. Pharingitis

Faringitis adalah infeksi oleh Grup A Hemolytic Streptococcus Beta yang nantinya akan menyebabkan demam rematik. Radang tenggorokan bagian belakang langit-langit lunak (faring). Streptolysin O dapat menyebabkan respons antibodi yang menunjukkan infeksi streptokokus. Streptococcus ini akan menempel pada dinding sel epithel dari membran mukosa di saluran pernapasan.

Symptom:- Fever- headache- muscle and joints aching- tenderness of cervical lymph nodes- tonsillar swelling

F. Hubungan menopause dgn kasusLevel of estrogen in blood circulation will decrease.Estrogen playing a vital role by guarding artery free from atherosclerotic plague (lipid,cholesterol,dead tissue cell) with increasing high density lipoprotein amount.

G. Cara Mendiagnosa- Anamnesis

a. Identitasb. Keluhanc. Riwayat penyakit sebelumnya (infeksi)d. Riwayat penyakit dalam keluargae. Riwayat pengobatan: obat yang digunakan, kepatuhanf. Aktivitas hariang. Riwayat konsumsi alcohol dan merokokh. Factor resiko

- Pemeriksaan Fisika. Status mentalb. Vital sign

Tekanan darah 110/70 mmHg normal HR 115 Bpm takikardi normalnya 60-100bpm RR 36x/menittakipneu normalnya 16-24 bpm

c. Status gizi

BMI=70

(1,55)2 =29,13obese 1

d. LeherJVP (5+2) mmH2Onormal (5+5)batas normal

e. Dada Basal rales (+) adanya bunyi ronkhi yang diperiksa dengan stetoscope

didaerah torak, ronkhi berupa suara serak2 seperti ada air, menandakan adanya edema didaerah paru-paru.

wheezing mengi, menandakan pasien mengalami sesak nafas.

f. Abdomen liver teraba 3 jari dibawah arcus costae hepatomegali

g. Ekstremitas minimal ankle edema adanya edema dijaringan, telah ada gagal janrtung

kanan dan perkembangan dari gagal jantung kiri

- Pemeriksaan Laboratorium

WBC15.000 (The normal range for WBC count is 4,300 to 10,800)- Pemeriksaan penunjang

Chest XRay- CTR (cardio-thorax ratio) = lebar jantung / lebar rongga thorax x 100- CTR > 50% = cardiomegaly

ECG- AF rapid ventricular respon = AF menandakan adanya gangguan di atrium- Left axis = Pada keadaan ini terjadi deviasi aksis kiri ( > 30o).

- LAH : Adanya pembesaran atrium kiri - RAH : Adanya pembesaran atrium kanan - RVH : Adanya pembesaran ventrikel kanan - LV Strain: Menunjukkan adanya pembesaran ventrikel kiri

Echocardiography- Thrombus attached to LA: There is the blood clots in the left atrium that can be

caused by mitral stenosis.

Hasil Nilai normal Interpretasi Total cholesterol 260 mg% < 200 mg% Hyperlipidemia Triglyseride 240 mg% < 200 mg% Lipoproteinemia Blood glucose 105 mg% < 200 mg% normal Glucose urine (-) (-) Normal SGOT 52 U/L 10-34 U/L heart@liver

damaged SGPT 43 U/L 0-40 U/L IMA,hepatitis,CHF

Total bilirubin 1.8 mg/dl 0.2-1.2 mg/dl Liver disease CK NAC 140 U/L 38-174 U/L Normal CK MB 25 U/L < 25 U/L 3-12j setelah IMA Troponin 0.1 ng/ml < 0.03 ng/ml 2-8j setelah IMA

- Ejection fraction 55%: it’s low ejection fraction. Normal : 65±8 %- Efusi Perikard minimal :The accumultion of fluid in the pericardium. The

compesation of pericardium effusion is tachycardia.- Vegetasi (+) : There is infective in endocarditis. The complication of endocarditis

is valve regurgitation and abcess.

H. Diagnosis BandingDISEASE Shortness

of breath Fatique Nausea Chest pain Fever Cough Palpitation

Aortic stenosis yes Yes No Yes No No Yes

Endocarditis Yes Yes No No Yes Yes No

Pericarditis Yes Yes No No Yes Yes No

Mitral valve prolapse

Yes Yes No Yes No No No

Myocarditis Yes Yes No Yes Yes No No

Congestive heart failure

Yes Yes No Yes Yes Yes No

Rhuematic heart diseases

Yes Yes Yes No Yes Yes Yes

CHF:

Mayor Criteria Minor Criteria

1. Paroxysmal Nocturnal Dypsnea

2. JVP ↑

3. Basal rales (+)

4. Cardiomegaly

5. Acute pulmonary edema

6. Gallop S3

7. Vena pressure >16cmH2O

8. Cardio jugular reflux

1. Ankle edema

2. Cough at night

3. Hepatomegaly

4. Pleura effusion

5. Tachycardia >120bpm

RHD:

Mayor Criteria Minor Criteria

1. Carditis

2. Migratory polyathritis

3. Subcutaneous nodules

4. Sydenham’s chorea

5. Erythema marginatum

1. Fever

2. Arthralgia

3. Leucocytes ↑

4. LED ↑

-2 kriteria mayor

-atau 1 kriteria mayor+2kriteria minor

I. Diagnosis Kerja CHF karena RHDCHF:Etiologi Umum:

- PJK- Infark miokardium- Hipertensi- Katup jantung pulmonal- Diabetes

Faktor Resiko:

- Diabetes - Merokok - Hipertensi - Obat - Obesitas - Deficiency vitamin

Manifestasi klinis:

- Lemah - Orthopnea - Fatigue - Nausea - Dyspnea - Ascites - Edema - Hepatomegali - JVP meningkat - Takikardia

RHD:

Etiologi: streptococcus grup A-β hemoliticus Patogenesis:

Streptococcus Group A-β Hemoliticusinfeksi saluran pernafasanfaringitisrespon imun (ASTO-Antibodi Streptolisin O)antibodi yg ditujukan pada protein M Streptokokus A bereaksi silang dengan protein normal yang terdapat di jantung, sendi, dan jaringan lainRHD

Manifestasi klinis:- Karditisperikarditis, miokarditis, endokarditis (pankarditis)- Poliartritis migransartralgia dan arthritis pada demam reumatik umumnya

mengenai lebih dari 1 sendi dan berpindah-pindah- Khoreagangguan saraf yang mengakibatkan gerakan bagian-bagian tubuh yang

tidak terkendali, lemah otot, dan gangguan emosi- Eritema marginatumkelainan berupa bercak kulit (rash)- Nodul subkutantonjolan2 keras di bawah kulit tanpa perubahan atau nyeri.

J. Management:- Untuk CHF:

a. meningkatkan oksigenasi dengan pemberian oksigen dan menurunkan konsumsi O2 melalui istirahat/pembatasan aktivitas (ABC, infus cairan)

b. memperbaiki kontraktilitas jantungmengatasi keadaan yang reversible termasuk tirotoksitosis,miksedema dan aritmia

digitalisasi

- dosis digitalis

digoksin oral untuk digitalisasi cepat 0,5-2mg dalam 4-6 dosis selama 24 jama dan

dilanjutkan 2x 0,5 mg selama 2-4 hari

digoksin iv 0,75-1 dalam 4 mg dalam 4 dosis selama 24jam

cedilanid iv 1,2-1,6mg dalam 24 jam

- dosis penunjang untuk gagal jantung; digoksin 0,25 mg sehari. Untuk pasien usia

lanjut dan gagal ginjal dosis

- dosis penunjang dioksin untuk fibrilasi untuk fibrilasi atrium 0,25mg

- digitalisasi cepat diberikan untuk mengatasi edema pulmonal akut yang berat :

digoksin : 1- 1,5 mg iv perlahan-lahan

cedilanid : 0,4-0,8mg iv perlahan-lahan

c. menurunkan beban jantung

menrunkan beban awal dengan diet rendah garam, diuretic dan vasodilator

a. diet rendah garam

pada gagal jantung dengan NYHA kelas IV,penggunaan diuretic, digoksin dan

penghambat ACE diperlukan mengingat usia harapan hidup yang pendek. Untuk gagal

jantung kelas II dan III diberikan :

1. diuretic dalam dosis yang rendah atau menengah (furosemid 40-80mg)

2. digoksin pada pasien dengan fibrilasi atrium maupun kelainan irama sinus

3. penghambat ACE (katropil mulai dari dosis 2x6,25 mg atau secara penghambat ACE

yang lain, dosis ditingkatkan secara bertahapdengan memperhatikan tekanan darah

pasien) ; isosorbid dinitrat (ISND) pada pasien dengan kemampuan aktivitas yang

terganggu atau adanya iskemia yang menetap, dosis dimulai 3x 10-15 mg. Semua

obat ini harus dititrasi secara bertahap.

b. Diuretik

Yang digunakan furosemid 40-80 mg. Dosis penunjang rata-rata 20 mg. efek

samping berupa hipokalemia dan dapat diatasi dengan suplai garam kalium atau

diganti dengan sprinokolakton. Diuretic lain yan dapat digunakan adalah

hidroklorotiazid, klortalidon, triamteren,amilorid dan asam etakrinat.

c. vasodilator

- Nitrogliserin 0,4-0,6 mg sublingual atau 0,2-2 ug/kgBB/menit iv

- Nitroprusid 0,5-1 ug/ k BB/menit iv

- Prazosin per oral 2- 5 mg

- Penghambat ACE ; katropil2x 6,25 mg

- Untuk RHD:a. Karditis dan kardiomegali tirah baring>6 minggu, mobilisasi bertahap>12 minggu,

dan diberikan prednisone 2mg/kgBB/hari selama 2 minggu dan diturunkan bertahap, serta salisilat 75mg/kgBB/hari mulai minggu ke 3 sampai minggu ke 6.

b. Khoreaklorpromazin, diazepam, haloperidol

K. Komplikasi- Stroke- Kematian mendadak- Cardiomyopathy.- Destroying of some organ function because of edema

VI. PrognosisDubia at malam Progosis gagal jantung berkaitan dengan derajat keparahannya. Kematian dapat terjadi karena gagal jantung progresif atau secara mendadak (diduga karena aritmia) dengan frekuensi yang kurang lebih sama

VII. Prevention and Educationa. Prevention

o Pencegahan terhadap endokarditis infektif diberikan pada setiap tindakan operatif seperti pencabutan gigi, luka, dan sebagainya.

o pencegahan emboli sistemik antikoagulan warfarino upaya pencegahan demam reumatik berulangparenteral penisilin G

b. Educationo Memberitahu pasien tentang gejala-gejala terulang kembali rheumatic fevero keyakinan dan ketaatan pasien untuk pencegahan sekunder ini secara spontan dan

penuh pengertian

VIII. KDU3B able to make clinical diagnosis based on physical examination and additional examination. Doctor could do preemptive therapy and refers to relevant specialist(emergency case)