Demographic Data

PATIENTS INITIAL :R

R/N : 0009801

SEX : Male

WARD : Ward1

AGE : 75 Year Old

OCCUPATION : Retired

MARTIAL STATUS : Married

ETHNIC GROUP : Malay

DATE OF ADMISSION : 19th May 2015

CHIEF COMPLAINT(S)

Mr. R, a 75 years old Malay gentleman a referral case from Hospital Selayang with a known
history of ischemic heart disease, presented to hospital Selayang on 17th of May with shortness of
breath on a day of admission.

HISTORY OF PRESENTING COMPLAINT(S)

Mr. R presented with shortness of breath on a day of admission. The symptoms suddenly
startedat night when he was reading a book. The shortness of breath lasting for 30 minutes until
he reached the hospital. It was associated with palpitation and sweating. However, there is no
aggravating factor like excercise or any works. On further questioning, he had a history of
several episodes of paroxysmal nocturnal dyspnea, but denied of having orthopnea.

Other than that, he also had chronic cough for 4 months duration. But it get worsen 4
days before admission associated with whitish sputum and also resolved fever 4 days before
admission. However no night sweat, no contact with TB patient, no hemoptysis.
SYSTEMIC REVIEW

Systems Symptoms

General No loss of weight, no loss of appetite, no sleep disturbances.

Respiratory system No hemoptysis, no dyspnea, no wheezing, no pleuritic chest

pain

Cardiovascular system No chest pain, no orthopnea, no leg swelling

Urinary system No changes in colour of urine, no blood in the urine, no

frothy urine

Skin & Musculoskeletal No rashes and no bruises, no joint pain

PAST MEDICAL/SURGICAL HISTORY

He was diagnosed with hypertension, diabetes mellitus and ischemic heart disease 2 years
ago. Stenting was done and under IJN follow up. He is compliant to the medication of diabetes
mellitus and hypertension.

DRUG HISTORY

Currently, he is on metformin, atorvastatin, valsartan, bisoprolol, furosemide and pantoprazole.

ALLERGIES

He has no allergy.

FAMILY HISTORY

Mr. R is the eldest. He does not know about other siblings illness. Both of his parent had passed
away. No illness was known during during their lifetime. No malignancy run in the family.

SOCIAL HSITORY

Mr. Z is a smoker for 50 years. He smoke 20 cigarette per day but reduced when he get older and
stopped after he was warded during the day of admission. He does not drink alcohol. He does not
work. He has 9 children and lives with them at Rawang and all his financial is supported by all
his children. Currently, he is taken care by his wife.
SUMMARY

Mr. R, a 75 years old Malay gentleman, a chronic smoker with a known history of ischemic heart
disease, hypertension and diabetes mellitus, presented with shortness of breath on a day of
admission associated palpitation, sweating and had history of paroxysmal nocturnal dyspnea.

PHYSICAL EXAMINATION

a) General examination

General condition
Mr. R was lying supine. He was alert, conscious, and well orientated to time, place and
people. He did look in pain. He was not in respiratory distress. His hydrational status was
adequate.

Height: 1.65 m
Weight: 55 kg
BMI: 20.2 kg/m2
Hands
His palm and sole were warm, dry and no evidence of palmar erythema. Capillary refill
time was less than 2 seconds. No clubbing, no peripheral cyanosis noted.

Eyes
His conjunctivae were not pale and no yellowish discoloration on his sclera.

Mouth
His hydrational status was good by the evidence of moist lips and mucous membrane. His
tongue was moist. There was oral thrush. No cyanosis noted.

Chest
No evidence of spider nevi and dilated vein.

Legs
He had no pedal edema.

Vital signs
Blood pressure : 130/70 mmHg
Pulse rate : 70 beats per minute with irregular rhythm and weak volume
Respiratory rate : 19 breaths per minute
Temperature : 37.0 OC
 Impression: Normal.

b) Systemic examination

Respiratory Examination

Inspection: There was no chest wall deformity. Chest wall moved symmetrically with
respiration. There was no surgical scars, no dilated vein and no visible pulsation. No usage of
accessory muscle noted.

Palpation: The trachea was centrally located. Apex beat situated at the 6th intercostal space at
midclavicular line over the left chest. Equal chest expansion was noted. Vocal fremitus was
normal.

Percussion: The lungs were resonance on percussion.

Auscultation: There was equal air entry on both lungs. Breath sound was heard, vesicular in
nature. Vocal resonance was normal.

Interpretation: No abnormalities noted.

Cardiovascular Examination

Inspection: Chest shape looked normal. There was no scar, no dilated vein, no visible pulsation
and no abnormal pigmentation or spider naevi. His jugular venous pressure (JVP) was raised.

Palpation: Apex beat was palpable at 6th left intercostal space of midclavicular line. There was
no heave and thrill and normal cardiac dullness noted. The radial, brachial, carotid, femoral,
popliteal, and pedal pulses were palpale. Dorsalis pedis pulses and posterior tibialis pulses at
both of his foot were present, normal and equal on both sides. No pedal edema.

Auscultation: Normal 1st and 2nd heart sound was heard. There was no murmur heard.

Interpretation: No abnormalities detected.

Abdominal Examination

Inspection: There was no abdomen distention. There is no surgical scar seen on inspection.
Palpation: On superficial palpation, the abdomen is soft and non tender. There is no mass can be
felt. On deep palpation, there is no hepatomegaly and splenomegaly.

Percussion: The were resonance on percussion all over the abdominal region.

Auscultation: Bowel sound is present.

Interpretation: No abnormalities noted.

CLINICAL SUMMARY

Mr. R, a 75 years old Malay gentleman, a chronic smoker with a known history of ischemic heart
disease, hypertension and diabetes mellitus, presented with shortness of breath on a day of
admission associated palpitation, sweating and had history of paroxysmal nocturnal dyspnea.

On physical examination, during CVS system examination, JVP was raised, and apex beat was
displaced.

PROVISIONAL DIAGNOSIS

Acute decompensated congestive cardiac failure secondary to lower respiratory tract infection.

Points to support:

1. Known history of ischemic heart disease

2. Shortness of breath associated with palpitation and sweating
3. Paroxsymal nocturnal dyspnea
4. Raised JVP
5. Worsen cough and fever

DIFFERENTIAL DIAGNOSIS

a) Acute coronary syndrome

Points to support Against by

- Shortness of breath - No chest or neck pain
- Cough - Has paroxysmal nocturnal dyspnea
- Palpitation
- Elderly
 b) Pulmonary embolism

Points to support Against by

- Shortness of breath - No pleuritic chest pain
- Cough - No hemoptysis
- Smoking
c) Community acquired pneumonia

Points to support Against by

- Shortness of breath - Palpitation
- Cough - PND
- History of fever

INVESTIGATION

1. Full Blood Count

Investigation Result Normal Range Status

RBC 5.49 4.50- 5.50/L Normal
Hemoglobin 11.5 11.5-16 g/dL Normal
Hematocrit 34.3 40.0-54.0 % Normal
WBC 13.26 2.0-11.0 x 109 /L High
Platelet 313 110-450 x 109 /L Normal

Interpretation: WBC is a bit high, indicates infection.

2. Renal Profile

Investigation Result Normal Range Status

Urea 16.8 2.5-6.7 mmol/L High
 Sodium 137 135-146 mmol/L Normal
Potassium 3.9 3.5-5.0 mmol/L Normal
Creatinine 129 79-118 umol/L High

Interpretation: The urea and creatinine level is raised which indicates renal failure.

3. Liver function test

Result Interpretation
Normal
range
Total 71.6 g/L Normal
64-83 g/L
Protein
Total
um
Bilirubi 7.6 Normal
<21
ol/L
n
Direct
um
Bilirubi 3.3 Normal
0-5
ol/L
n
Alanine
Transa 15.6 Normal
<33 U/L
minase
Albumi 37.6 Normal
35-52 g/L
n
Alkaline 73.7 Normal
35- U/L
 phosph
104
atase
Interpretation: No abnormalities detected.

4. Cardiac enzymes

Enzyme Results Normal value

CKMB 3.22 0-3

Troponin 0.695 <0.2mcg/L

Interpretation: Both CKMB and troponin are high which indicate necrosis of the heart cells or
muscle.

5. ECG
Regular sinus rhythm about 75 beats per minute

6. Angiography
FINAL DIAGNOSIS

Decompensated cornary cardiac failure secondary to pneumonia.

PRINCIPLES OF MANAGEMENT

Pharmacological
- Normal saline
- T. Prednisolone 40mg BD
- T. Bisoprolol 1.25mg OD
- To continue medication from hospital Selayang

Surgical
- Not decide yet
DISCUSSION

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.

Heart failure may be caused by myocardial failure but may also occur in the presence of normal
cardiac function under conditions of high demand. Heart failure always causes circulatory
failure, but the converse is not necessarily the case, because various noncardiac conditions such
as hypovolemic shock and septic shock can produce circulatory failure in the presence of normal,
modestly impaired, or even supranormal cardiac function. To maintain the pumping function of
the heart, compensatory mechanisms increase blood volume, cardiac filling pressure, heart rate,
and cardiac muscle mass. However, despite these mechanisms, there is progressive decline in the
ability of the heart to contract and relax, resulting in worsening heart failure. In Mr. R case, he
has history of ischemic heart disease and treated at IJN. As time goes by, the condition of the
heart slowly become worsen though he been treated with stenting, plus fever or pneumonia that
precipitated his heart condition make him came to the hospital with shortness of breath.

Signs and symptoms of heart failure include tachycardia and manifestations of venous
congestion (eg, edema) and low cardiac output (eg, fatigue). Breathlessness is a cardinal
symptom of left ventricular (LV) failure that may manifest with progressively increasing
severity. In this case, Mr, R has both left and right cardinal symptoms. He presented with
shortness of breath associated with palpitation and on physical examination revealed raised JVP.

Heart failure can be classified according to a variety of factors (see Heart Failure Criteria and
Classification). The New York Heart Association (NYHA) classification for heart failure
comprises 4 classes, based on the relationship between symptoms and the amount of effort
required to provoke them, as follows :

i. Class I patients have no limitation of physical activity

ii. Class II patients have slight limitation of physical activity
iii. Class III patients have marked limitation of physical activity
iv. Class IV patients have symptoms even at rest and are unable to carry on any physical
activity without discomfort

I did ask this patient regarding his daily activities, I categorized him as class 2 as he has slight
limitation towards physical activity. He claimed that sometimes he need to rest a bit after doing
some physical activity such as gardening and housekeeping.
From a clinical standpoint, classifying the causes of heart failure into the following 4 broad
categories is useful:

I. Underlying causes: Underlying causes of heart failure include structural abnormalities

(congenital or acquired) that affect the peripheral and coronary arterial circulation,
pericardium, myocardium, or cardiac valves, thus leading to increased hemodynamic burden
or myocardial or coronary insufficiency

II. Fundamental causes: Fundamental causes include the biochemical and physiologic
mechanisms, through which either an increased hemodynamic burden or a reduction in
oxygen delivery to the myocardium results in impairment of myocardial contraction

III. Precipitating causes: Overt heart failure may be precipitated by progression of the
underlying heart disease (eg, further narrowing of a stenotic aortic valve or mitral valve) or
various conditions (fever, anemia, infection) or medications (chemotherapy, NSAIDs) that
alter the homeostasis of heart failure patients

IV. Genetics of cardiomyopathy: Dilated, arrhythmic right ventricular and restrictive

cardiomyopathies are known genetic causes of heart failure.

In this case, the patient has underlying cause ( diabetes, hypertension, previous ischemic heart
disease) and precipitating cause which is pneumonia 4 days before the admission.

Careful evaluation of the patient's history and physical examination (including signs of
congestion, such as jugular venous distention can provide important information about the
underlying cardiac abnormality in heart failure. However, other studies and/or tests may be
necessary to identify structural abnormalities or conditions that can lead to or exacerbate heart
failure.

Complete blood count (CBC), which in this patient (raised WBC) indicate infection as
potential causes of heart failure

Serum electrolyte levels, which was abnormal owing to causes such as fluid retention or
renal dysfunction

Blood urea nitrogen (BUN) and creatinine levels, which was raised and may indicate
decreased renal blood flow

Liver function tests (LFTs), which may show elevated liver enzyme levels and indicate liver
dysfunction due to heart failure

Electrocardiogram (ECG) (12-lead), which may reveal arrhythmias, ischemia/infarction, and

coronary artery disease as possible causes of heart failure
The goals of treatment for people with chronic heart failure are the prolongation of life, the
prevention of acute decompensation and the reduction of symptoms, allowing for greater activity.

Heart failure can result from a variety of conditions. In considering therapeutic options, it is
important to first exclude reversible causes, including thyroid disease, anemia,
chronictachycardia, alcohol abuse, hypertension and dysfunction of one or more heart valves.
Treatment of the underlying cause is usually the first approach in treating heart failure. However,
in the majority of cases, either no primary cause is found or treatment of the primary cause does
not restore normal heart function. In these cases, behavioral, medicaland device treatment
strategies exist which can provide significant improvement in outcomes, including the relief of
symptoms, exercise tolerance, and a decrease in the likelihood of hospitalization or death.
NAME OF STUDENT: MUHAMMAD IDZWAN AZIZI BIN MOHD JAIS

MATRICS NO: 2011834652

SUPERVISORS COMMENTS ON CASE WRITE-UP

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MARKS (out of 10):

NAME OF SUPERVISOR:

SIGNATURE :

DATE : 13TH FEBRUARY 2015

 FACULTY OF MEDICINE
CARDIOLOGY POSTING
YEAR 4

CASE WRITE UP

NAME : MUHAMMAD IDZWAN AZIZI BIN MOHD JAIS

NO MATRIX : 2011834652

GROUP : 2