case report chf

12

CASE REPORT

Name: Jihan Talita Ulfa SiregarAge: 11 months 16 days Sex: FemaleDate of Admission: December, 21th 2014

Chief Complaint: Shortness of BreathHistory: These was realized by the Os parents one month ago. Restlessness and shortness of breath was seen during activities such as when Os is crying and consuming milk. These complain was encountered by os since birth but it got worst in this few months. In the past two months, Os has a history of interrupted consumption of milk and heavy sweating during consumption of milk. Fever (-), diarrhea (-), cough (+) flam (-), vomiting (-) and sweating (+) in the last one month. Os have defecation problem (constipation) in the last two weeks. Os has no urination problem.

Pregnant HistoryPatient was conceived at second pregnancy at the age 28, first child (2 yrs old): normal delivery and healthy. There was no history of fever, hypertension, diabetic mellitus, and consumption of drugs and herbal medicine as well jaundice during pregnancy period.

Birth HistorySpontaneous; attended by midwives; BW 3800 gram; BL 50 cm, cyanotic (-)

Immunization HistoryBCG I (no scar), DPT II, Polio III, Measles I, Hepatitis III

Feeding HistoryFrom birth to 4 months: Breast milk onlyFrom 4 months up to date : Breast milk, biscuit porridge (SUN) and Formulated Milk

History of Growth and DevelopmentSitting: - months Crawling: - monthsStanding: - monthsWalking: - months

History of previous illness: The patient has been suffering from growth stunt where the growth doesnt match the age and was experiencing shortness of breath when crying and ingesting milk for almost more than a month. Patient was then brought by the parents to Tapsel District General Hospital and was diagnosed as noncynotic CHF. Later the patient was then referred to Dr. Pringadi District General Hospital where was diagnosed as CHF ec acynotic CHD. Finally the patient was referred to Haji Adam Malik General Hospital on the 21th of Dec 2014.

History of previous medications: none

History of Family Disease: unclear

Pysical ExaminationGeneralized statusBody weight: 5kg, Body length: 62 cmBody weight in 50th percentile according to age: 8.5 kgBody length in 50th percentile according to age: 73 cmBody weight in 50th percentile according to body length: 6.5 kg

BW/BL: 5/6.5 x 100% = 77 % (Moderate Malnutrition)BW/age: 5/8.5 x 100% = 59 % (Severe Malnutition)BL/age : 62/73 x 100% = 85% (Mild malnutrition)Weight for lenght: -3 < Z scores < -1 (underweight)

Presens statusConsciousness: Compos mentis , Body temperature: 36,7 oC. HR 140x/i, RR 50x/i, BP 90/70 mmHg, Anemic (-); Icteric (-); Cyanosis (-); Edema (-). Dyspnea (+).

Localized statusHead : Large crown closed. Black hair, normal. Right Eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-). Icteric sclera (-). Light reflex (+). Left eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-). Icteric sclera (-). Light reflex (+).Ear, nose and mouth were within normal limit. Neck : Lymph node enlargement (-). TVJ R+2 cmH20

Thorax: Symmetrical fusiformis. Chest retraction (+) epigastrial, intercostals, suprasternal. HR: 140 bpm, regular, murmur (+) pansistolik grade III/6 LMCS ICR III-IV.RR: 50x/i, ireguler, rales -/-Abdomen: Soepel, Normoperistaltic. Liver, spleen and renal unpalpable.. Extremities: Pulse 136x/i, regular, adequate p/v, warm acral , CRT < 3.

Urogenital: Female; within normal limit.

Laboratory Findings (December, 21st 2014):ParametersValueNormal Value

Complete Blood Count

Hemoglobin10.30 gr%12,0 14,4 gr%

Hematocrite31.60 %37 41%

Erithrocyte4.06 x 106 /mm34,40 4,48 x 106 /mm3

Leucocyte12.06 x 103 /mm34,5 13.5x 103 /mm3

Platelet385.000 /mm3150.000 450.000 /mm3

MCV77.80 fl81 95 fl

MCH25.40 pg25 29pg

MCHC32.60 gr%29 31 gr%

RDW18.80 %11.6 14.8 %

MPV7.80 fl7,0 10,2 fl

PCT0.30%

PDW7.2%

Hitung Jenis

Neutrofil24,3037-80

Limfosit70,0020-40

Monosit5,202-8

Eosinofil0,201-6

Basofil0,3000-1

Neutrofil absolute2.921,9-5,4

Limfosit absolute8,443,7-10,7

Monosit absolute0.630,3-0,8

Eosinofil absolute0.030,2-0,5

Basofil absolute0,040-0,1

Laboratory Findings (December, 21st 2014):ParametersValueNormal Value

Carbohydrate Metabolism

Blood Glucose ad random91,00 mg/dL< 200

AGDA

pH7,4377,35 7,45

pCO221,7 mmHg38 42

pO2137,7 mmHg85 100

Bicarbonate (HCO3) 14,3 mmol/L22 26

Total CO215,0 mmol/L19 25

Base Excessive (BE)-8.6 mmol/L(-2) (+2)

O2 Saturation 99.1%95 - 100

Cardiac Marker

Troponin TNegative (g/L)0 0,1

Radiologic Imaging

Figure 8:The chest x-ray of the patientChest x-ray interpretation:J P G , 9 year 4 month, Mr, August 27th 2014.KV weak. Less Inspiration, no trachea deviation found(middle trachea), both costophrenicus angel were sharp, smooth diaphragm, not seen infiltrates in both lung fields, Heart has a boots shaped. Cardio Thoracic Ratio is enlarged to the left lateral with, Cardio thoracic Ratio is more than 50 %, apex embedded (apex downward), bones and soft tissues in good condition, waist of heart not prominent.Result: Tetralogy of Fallot with lung edema.

EKG

Interpretasi:Sinus tachycardia, reguler, HR :111x/i, Right Axis Deviation, P Pulmonal Lead II, interval PR 0,14 s, Q patologis (-), QRS interval 0,08s, T inverted (V1 V4), ST elevation (-), ST depresion (-) RAD (+) RVH (+) LVH (+), iscemic anteroseptal, S persisten V5,V6.Result :P pulmonal, Biventricular hipertrophy (+), iscemic anteroseptal

Ecocardiography

Right Ventricular hipertrofi, VSD Pulmonary stenosis seen. RPA 8,9 mm. LPA 10,9 mm overriding aorta 50% Ejection Fraction 12%, FS 5%Result : Pulmonary stenosis and Overriding aorta

Differential Diagnosis: VSD ASD PDA

Working Diagnosis:CHF ec acynotic CHD

Management: Bed rest O2 Nasal kanul L/i Furosemide 2x5mg Spironolactone 2x6,25mg Sildenafil 3x1.5mg IV Dobutamin 5mcg/kgbw/minute (75mg in 50cc Nacl 0.9%) in 1cc perhour

Diagnostic Planning: Consul cardiologist Urinalysis Echocardiography

FOLLOW UP

December , 21 -22 th 2014

S Dyspnoe +

OSens: Compos mentis, Temp: 36,7 oC. Anemic (-). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (+)Body weight: 5 kg, Body length: 62 cmHeadRight Eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-). Icteric sclera (-). Light reflex (+). Left eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-). Icteric sclera (-). Light reflex (+)..

NeckLymph node enlargement (-)

ThoraxSimetris fusiformis. Retraction (+) epigastrial; intercostals, suprasternal. HR: 150 bpm, reguler; murmur (+) pansistolik grade III/6 LMCS III-IV.RR: 50 x/i, regular, rales (-/-)

AbdomenSoepel. normoperistaltic. Liver, spleen and renal unpalpable.

ExtremitiesPulse 140 x/i, iregular, adequate p/v, warm, CRT < 3.

GenitalFemale; within normal limit.

ACHF ec acynotic CHD ec dd/ VSD ASD PDA

PManagement: Bed rest O2 Nasal kanul L/i Furosemide 2x5mg Spironolactone 2x6,25mg Sildenafil 3x1.5mg IV Dobutamin 5mcg/kgbw/minute (75mg in 50cc Nacl 0.9%) in 1cc perhour

Diagnostic Planning: Echokardiografi Urinalisis Consul kardiologist


S Dyspnoe +









Diagnostic Planning: Echokardiografi


S Dyspnoe +









Diagnostic Planning: Echokardiografi

26th December 2014Patient exitus after sudden drop in blood pressure and worsening dyspneo. Resuscitation failed. Cause of death is suspected aspiration of fluid into lungs.

case report chf

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