Case report

Cor Pulmonal
Chronic
Yanis Indiana Yacma
Preceptor :

dr. Nurkhalis, Sp.JP-FIHA

Laporan Kasus
Name
: Tn.R
Sex
: Man
Age
: 31 years old
Religion
: Islam
Ethnic
: Aceh
Adress
: Pidie
Occupation
:No. RM
: 1051747
Date on arrival : 12 Mei 2015
Date on examination: 5 Juni 2015

Anamnesis
Chief complaint:
Dyspneu

Weak, cough, fever, chest

pain

Current medical history: The patient came to the emergency department with
dyspneu, its happened from 3 months ago and feel more in 2 days ago. Itsnt
have a correlation between temperature and food. Firstly the dyspneu not
effected from activity, but now patient feel dyspneu when do some daily
living activity. Patient also got a cough. A cough with a mucous secret and
sometimes with blood. Now patient feel cannt do daily activity, he just lay in
his bed. He also have a fever. A chest pain for patient feel sometimes, its also
feel in his back. Now he say he feel weight loss in several months.

 Past medical history : patient have already hospitalize in RSUZA 3

months ago with bronkiektasis and old TB with destroyed lung. 2 years
ago patient has already consumed OAT for 9 months.

Family medical history : No family members of patients who experienced

symptoms like the patient. A family history of lung TB is denied.

A history of drugs use : OAT, Levofloxacin 1x500 mg,

sohobion, digoxin 3x0,25mg

A history of social habit : patient cannt do daily activity, and

just in a bed.

VITAL SIGN (5 June 2015)

Physical Examination
Skin
Head
Faces
Eyes
Ears
Nose
Mouth
Neck

: brown, jaundice (-), cyanosis (-), edema (-)

: hair normal distribution, it is difficult revoked
: symmetrical, edema (-), deformity (-)
: anemic (+ / +), jaundice (- / -), secretions (- / -),
RCL (+ / -), RCTL (- / -), pupil isokor -/: normotia impression, secret (- / -)
: secret (- / -), hyperemia (-), NCH (-)
: dry mucous (-), cyanosis (-)
: suprasternal retraction (-), lymphadenopathy (-),
stiff neck (-), TVJ: R+2 cmH2O.

 Anterior thoracic
Inspection
Static
Dynamic
Palpation
Percussion
Percussion
Auscultation
Auscultation
wheezing
wheezing ((- // +)
+)

: Symmetric
: Asymmetric
: Left SF > right SF, tenderness (+/-),
crepitus
crepitus ((- // -)
-)
:: Dim/
Dim/ hypersonor
hypersonor
:: Vesicular
Vesicular ((- // +),
+), rhonki
rhonki (+
(+ // +)
+) 2/3
2/3 lower
lower lung,
lung,

 Posterior thoracic
Inspection
Inspection
Static
Static
Dinamic
Dinamic

Palpation
Palpation
Percussion
Percussion
Auscultation
Auscultation
(-/+)
(-/+)

:: symetris
symetris
:: Asymetris
Asymetris

:: right
right SF<left
SF<left SF
SF , crepitus
crepitus (-/-)
(-/-)
:: Dim/hypersonor
Dim/hypersonor
:: vesikuler
vesikuler (-/+),
(-/+), rhonki (+/+),
(+/+), wheezing
wheezing

Heart
Inspection
Inspection
:: ictus
ictus cordis
cordis not
not visible
Palpation
Palpation :: ictus
ictus cordis
cordis palpable
palpable in
in ICS
ICS IV,
IV, right
right
midcalivularis
midcalivularis line.
line.
Percussion
Percussion
:: cardiac
cardiac border
border
Up
Up
Left
Left
Right
Right

:: ICS
ICS III
III left
left parasternal
parasternal line
line
:: ICS
ICS V
V left
left parasternal
parasternal line
line
:: ICS
ICS III
III right
right axillaris
axillaris anterior
anterior line
line

Auskultation:
Auskultation: heart
heart sound
sound II >
> Heart
Heart sound
sound IIII in
in right
right
hemithoraks,
hemithoraks, reguler
reguler (+),
(+), noisy
noisy (-),
(-), gallop
gallop (-),
(-), murmur
murmur (-).
(-).

Abdomen
Inspection
Inspection
symetric,
symetric, distension
distension (-),
(-), collateral
collateral vein
vein (-),
(-), scar
scar (+)
(+)
Palpation
Palpation
organomegaly
organomegaly (-), tenderness (-), defans muscular
muscular (-)
Percussion
Percussion
timpani,
timpani, shifting
shifting dullness
dullness (-),
(-), undulation
undulation (-)
(-)
Auscultation
Auscultation
peristaltic
peristaltic normal
normal

Exremity
cyanosis
cyanosis (-),
(-), clubbing
clubbing finger
finger (-),
(-), edema
edema (-/-) capillary
capillary refill
time
time > 3s

Table 2.4 Laboratory: Date 25-05-2015

Pemeriksaan
Laboratorium

Hasil

Nilai Normal

Hb

10,5 gr/dl

12-15 gr/dl

Ht

34 %

37-47 %

Leukosit

6.400 /mm3

4.500-10.500/mm3

Eritrosit

4,4 x 106 /L

4,2-5,4 jt/ L

224.000 / mm3

150.000-450.000/mm3

Darah Rutin

Trombosit
Hitung Jenis

Eosinofil

0-6

Basofil

0-2

Netrofil batang

0-1

Netrofil segmen

65

50-70

Limfosit

22

20-40

Monosit

2-8

Natrium (Na)

141 mmol/L

135-145 mmol/L

Kalium (K)

4,7mmol/L

3,5-4,5 mmol/L

Klorida (Cl)

96 mmol/L

90-110 mmol/L

Elektrolit

Diabetes
Glukosa Darah Sewaktu

<200 mg/dl

Ginjal-Hipertensi
Ureum
Kreatinin

13-43 mg/dl
0,51-0,95 mg/dl

Table 2.4 Laboratory: Date 05-06-2015

Pemeriksaan
Laboratorium

Hasil

Nilai Normal

Hb

11,1 gr/dl

12-15 gr/dl

Ht

35 %

37-47 %

Leukosit

16.800 /mm3

4.500-10.500/mm3

Eritrosit

4,7 x 106 /L

4,2-5,4 jt/ L

287.000 / mm3

150.000450.000/mm3

Darah Rutin

Trombosit

Hitung Jenis

Eosinofil

0-6

Basofil

0-2

Netrofil batang

0-1

Netrofil segmen

76

50-70

Limfosit

11

20-40

Monosit

11

2-8

Natrium (Na)

142 mmol/L

135-145 mmol/L

Kalium (K)

3,0 mmol/L

3,5-4,5 mmol/L

Klorida (Cl)

95 mmol/L

Elektrolit

Kalsium (Ca)
Ginjal-Hipertensi
Ureum
Kreatinin

90-110 mmol/L
8,6-10,3 mg/dl

13-43 mg/dl
0,51-0,95 mg/dl

Examination
Electrocardiogram (EKG)
04/06/2015

Onterpretation:
Rhythm : Sinus, regular
Rate
: 300/3 = 100 x / min
axis: RAD
P wave
: 0.08 s 0.1 mV
PR interval
: 0.16 s
QRS
: 0.08 s
pathological Q: (-)
T inverted
: II, III, AVF, V1
ST elevation
: (-)
ST depression: (-)
RSR
: Conclusion: Sinus, regular, HR 100 x / min, RAD, ischemic inferior

Plain Photo examination thoraks

Conclusion:

Old fracture clavicula dextra, destroyed

lung, old TB.

Working diagnosis
Cor pulmonal chronic
Bronkiektasis with destroyed lung
Pneumonia

Therapy
Therapy of cardio:
Bed Rest
IVFD NaCl 15 gtt/i
O2 2-4 l/i
Inj Lasix 1 amp/12 H
Digoxin 1x0,25 mg
Sildenafil 2x12,5 mg
Therapy of Pulmonology:

Bedrest
IVFD Futrolit 10 gtt/i
Asam traneksamat 3x500mg
Nebule ventolin / 8 H
Fosfomycin 1gr/12 H
Sucralfat syr 3xCI

Planning

1. ECHO
2. Follow up ECG
3. Blood gas analysis

Prognosis

Quo ad vitam
: dubia ad malam
Quo ad fungsionam: dubia ad malam
Quo ad sanactionam
: dubia ad malam

 Impaired gas exchange related to

expiratory airflow obstruction as
evidenced by decreased oxygen
saturation levels and also make
patient dyspneu
Activity intolerance related to
decreased cardiac activity and
laboured respirations as evidenced
by difficulty in performing activities
of daily living

 Decreased cardiac output related to

restricted cardiac muscle
contractility as evidenced by
echocardiographic finding
Impaired tissue perfusion, and
airflow change in lung, related to
decreased cardiac contractility and
expiratory airflow obstruction also
can be effected capillary refilling
time >3 seconds

Definition
It is the hypertrophy of the right
ventricle resulting from diseases
affecting the function and/or
structure of the lung, except when
these pulmonary alterations are
the result of diseases that
primarily affect the left side of the
heart or congenital heart
World heart association

Etiology
Conditions that restrict or compromise ventilatory
function, leading to hypoxemia or acidosis e.g.
deformities of the thoracic cage, massive obesity
Conditions that reduce the pulmonary vascular
bed e.g. primary idiopathic pulmonary arterial
hypertension, pulmonary embolus
Disorders involving nervous system, respiratory
muscles, chest wall , and pulmonary arterial tree
may also be responsible for cor pulmonale

PATHOGENESIS

GENETIC CAUSES

UNKNOWN CAUSES

PATHOGENESIS
CONTINUED

PULMONARY ENDOTHELIAL INJURY

PATHOGENESIS
CONTINUED
VASOCONSTRICTION

REMODELLING

PATHOGENESIS
CONTINUED
SUSTAINED PULMONARY HYPERTENSION

RIGHT VENTRICULAR HYPERTROPHY

PATHOGENESIS
CONTINUED
COR PULMONALE

CLINICAL MANIFESTATIONS
Dyspnea
Chronic productive
cough
Wheezing
respirations
Retrosternal or
substernal pain
Fatigue
Polycythemia

Peripheral edema
Weight gain
Distended neck veins
Full bounding pulse
Enlarged liver
Palpitation
Atypical chest pain
Swelling of the lower extremities
Dizziness and even syncope

DIAGNOSIS
HISTORY COLLECTION

DIAGNOSIS
PHYSICAL EXAMINATION

DIAGNOSIS
LABORATORY TESTS

DIAGNOSIS
CHEST
RADIOGRAPHY

DIAGNOSIS
ELECTROCARDIOGRAPHY
ECHOCARDIOGRAPHY

DIAGNOSIS
CARDIAC CATHETERIZATION

DIAGNOSIS
LUNG BIOPSY

3 Major Physiological Goals of

Cor Pulmonale Treatment
1. Reduce the right ventricular after load
causing a reduction of the pulmonary artery
pressure.
2. Decrease right ventricular pressure.
3. Improve the contractility of the right
ventricle.

MEDICAL MANAGEMENT
OXYGEN THERAPY

MEDICAL MANAGEMENT

PHARMACOTHERAPY
Diuretic agents
Vasodialators
Digitalis
Anticoagulant

Thank you

Signs And Symptoms

Dyspnea - The Most Common Symptoms

As The Result Of The Increased Work Of Breathing Secondary To Changes In

Elastic Recoil Of The Lung (Fibrosing Lung Diseases) Or Altered Respiratory
Mechanics
Such As : Overinflation With COPD

Orthopnea And Paroxysmal Nocturnal Dyspnea

Reflect The Increased Work Of Breathing In The Supine Position That Results
From Compromised Excursion Of The Diaphragm

Tussive Or Effort Related Syncope

In Patients With Severe Pulmonary Hypertension Because Of The Inability Of
The RV To Deliver Blood Adequately To The Left Side Of The Heart

Abdominal Pain And Ascites - Due To Right Heart Failure

Lower Extremity Edema
Due To Neurohormonal Activation, Elevated RV Filling Pressures, Or
Increased Levels Of Carbon Dioxide And Hypoxia, Which Can Lead To
Peripheral Vasodilatation And Edema Formation

Tachypnea

 Elevated Jugular Venous Pressure

With Prominent V Waves As A Result Of Tricuspid Regurgitation
Hepatomegaly, Lower Extremity Edema
RV Heave
Palpable Along The Left Sternal Border Or In The Epigastrium
Systolic Pulmonary Ejection Click
May Be Audible To The Left Of The Upper Sternum
Holosystolic Murmur Of The Tricuspid Regurgitation
(CARVALLO'S SIGN)
Cyanosis (LATE FINDINGS)
Secondary To A Low Cardia Output With Systemic
Vasoconstriction And Ventilation Perfusion Mismatches In The
Lung