+ Clerkship of Department of Internal Medicine

Atma Jaya University - Faculty of Medicine

St. Antonius Hospital Pontianak
2017

Case Presentation
Supervised by :
Ruddy Alex Ticonuwu, MD - Internist

Presented by : Melisa Putri (2014-061-141)

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Case Presentation
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Patients Identity
Name : Mr. K

Age : 49 years old

Gender : Male

Address : Sanggau

Occupation : Laborer

Education Background : Middle School

Religion : Christian

Date of Admission : 29th January 2017

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Patients History

Chief Complain :
Shortness of breath since 1 week before admission to the hospital

Additional Complain :
Swollen legs
since 1 week prior to admission
Fatigue
Fever
since 3 days prior to admission
Cough with phlegm
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History of Present Illness

3 days
Shortness of breath
before The shortness of breath
cant walk too far, admission getting worsen, the
relieved by resting Shortness of breath (+), patient cant even walk
The patient slept with 2
swollen legs (+), fatigue (+) to the restroom
Cough with phlegm Swollen legs (+), fatigue
pillows phlegm color was white, no
(+), fever (+), cough with
Swollen legs & fatigue blood stains
phlegm (+)
Fever the temperature was
not measured with
1 week prior thermometer Admission to
to admission the hospital
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History of Past Illness

History of Type 2 Diabetes Mellitus he was just diagnosed

5 months ago, he routinely consumed medicine for diabetes
(Metformin 3 x 500 mg)

History of hypertension

History of heart disease

denied
History of pulmonary disease

History of allergies
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Family History of Disease

History of family member who had the same symptoms was

denied

History of diabetes mellitus

History of pulmonary diseases denied

History of heart disease

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Physical Examination

General appearance : moderately ill

Consciousness : conscious (E4M6V5)

Vital signs
Blood pressure : 90/70 mmHg
Respiratory rate : 32 times/minute
Pulse : 116 times/minute
Temperature : 36.4C

Nutritional status
Weight : 50 kg
Height : 165 cm
BMI : 18.3 kg/m2 underweight
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Physical Examination

Head : normocephaly, deformity (-)

Eyes : pallor conjuctiva +/+, white sclera +/+, pupil isochor

3mm/3mm, light reflex +/+

Ears : cerumen -/-, intact tympanic membrane +/+, secret -/-

Nose : septum deviation (-), crepitation (-), secret -/-

Mouth : oral mucosa and lips are moist, tonsil T1/T1

Neck : JVP 5 + 2 cm H2O, lymph node enlargement (-),

abdominojugular reflux (-)
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Chest Examination
Lungs :
Inspection : symmetrical chest expansion, no retraction
Palpation : symmetrical fremitus tactile on both lungs
Percussion : resonant on both lungs, liver dullness on ICS VI right
midclavicular line
Auscultation : vesicular +/+, rhonchi +/+, wheezing -/-
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Chest Examination

Heart :
Inspection : apical impulse was not visible
Palpation : apical impulse was palpable in ICS V left midclavicular line
Percussion : upper border : ICS III left parasternal line
right border : ICS IV right parasternal line
left border : ICS V left anterior axillary line
Auscultation : first and second heart sounds are regular, murmur (-),
gallop (-)
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Physical Examination
Abdomen
Inspection : flat abdomen
Auscultation : bowel sounds 8 times/minute, metallic sound (-)
Palpation : supple, tenderness (-), hepatomegaly (+)
Percussion : tympanic, shifting dullness (-)

Back
Inspection : normal vertebral alignment
Palpation : symmetrical fremitus tactile
Percussion : resonant +/+
Auscultation : vesicular +/+, rhonchi +/+, wheezing -/-
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Physical Examination

Extremities :
Warm extremities
CRT < 2
Edema (-/-/+/+)
Motoric strength 5/5/5/5
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Laboratory Test

Hematology Results Unit Normal Value

Hemoglobin 9.1 g/dL 13.0 17.5
Hematocrit 27.3 % 40.0 52.0
Erythrocytes 3.2 Million/L 4.5 5.5
Leukocytes 12,500 /L 4,000 11,000
Thrombocytes 425,000 /L 150,000 400,000
MCV 86.4 fL 77.0 96.0
MCH 28.8 pg 27.0 32.0
MCHC 33.3 g/dL 31.0 35.0
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Laboratory Test

Clinical Chemistry Results Unit Normal Value

AST 105 U/L 0 - 37
ALT 34 U/L 0 - 42
Total Cholesterol 106 mg/dL < 220
HDL 7 mg/dL > 55
LDL 34 mg/dL < 150
Triglycerides 110 mg/dL < 200
Ureum 14.2 mg/dL 10 - 50
Creatinine 0.68 mg/dL 0.5 1.2
Random Serum Glucose 108 mg/dL 80 150
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Chest X-Ray

Cloudy opacity in the

middle lobe of right lung

CTR > 50%

Conclusion :
Cardiomegaly
Pneumonia
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ECG
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Summary

Male, 49 years old presented with dyspnea, fatigue and bilateral

edema since 1 week before admission to the hospital. Fever and
cough with white phlegm since 1 week prior to admission.

From the physical examination, we found the patient was

underweight (BMI : 18.3 kg/m2), Eyes : pallor conjunctiva +/+,
Lungs : rhonchi +/+, Heart : cardiomegaly, Abdomen :
hepatomegaly (+), Extremities : edema -/-/+/+

From the laboratory examination we found anemia (Hb : 9.1 g/dL),

leukocytosis (12,000 /L), and slight elevation of AST (AST : 105
U/L)

From the Chest X-ray, we found cardiomegaly with pneumonia.

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Diagnosis

Congestive Heart Failure NYHA FC III

Community Acquired Pneumonia

Diabetes Mellitus Type 2

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Treatment

Hospitalization Levofloxacin 1 x 750 mg IV

Fluid restriction Paracetamol 3 x 500 mg PO (if

body temperature > 38C)
Oxygen supplementation
Phlegm gram stain and
Furosemide 1 x 20 mg IV antibiotic resistance test

Captropil 3 x 6.25 mg PO Echocardiography

Bisoprolol 1 x 1.25 mg PO

Metformin 3 x 500 mg PO
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Literature Review
2016 ESC Guidelines for the diagnosis and treatment of acute
and chronic heart failure
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Definition (AHA)

Heart failure is a complex clinical syndrome that results from

structural or functional impairment of ventricular filling or
ejection of blood, which in turn leads to the cardinal clinical
symptoms of dyspnea and fatigue and signs of heart failure,
namely edema and rales.
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Etiologies
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NYHA Classification
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Pathogenesis
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Signs and
Symptoms of
Heart Failure
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Additional Tests

Routine Laboratory Test (CBC, electrolytes, BUN, serum creatinine, hepatic

enzymes, and urinalysis) Special case : DM serum glucose,
Dyslipidemia serum cholesterol & triglycerides, Thyroid disease TSH

ECG MCI

Chest X-ray size and shape of heart, presence of pulmonary edema

Echocardiography LV function

Biomarker BNP, N-terminal pro-BNP, soluble ST-2 and galectin-3

Exercise Testing treadmill / bicycle exercise testing need for cardiac

transplantation (peak oxygen uptake < 14 mL/kg/min)
+ Management
of Heart Failure
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+ Heart Failure and Diabetes
Recommendation
Metformin is safe and effective and it should be the treatment
of choice in patients with HF, but is contraindicated in patients
with severe renal or hepatic impairment, because of the risk of
lactic acidosis.

Insulin is required for patients with type 1 diabetes and to

treat symptomatic hyperglycemia in patients with type 2
diabetes and pancreatic islet b cell exhaustion. However,
insulin is a powerful sodium-retaining hormone, and when
combined with a reduction in glycosuria, may exacerbate fluid
retention, leading to HF worsening.
+ Heart Failure and Diabetes
Recommendation
Sulphonylurea derivatives have also been associated with an
increased risk of worsening HF and should be used with
caution.

Dipeptidylpeptidase-4 inhibitors (gliptins), which increase

incretin secretion, thereby stimulating insulin release, and
long- acting glucagon-like peptide 1 (GLP-1) receptor
agonists, which act as incretin mimetics, improve glycaemic
indices but do not reduce and may increase the risk of
cardiovascular events and worsening HF. Importantly, there
are no data on the safety of gliptins and GLP-1 analogues in
patients with HF.
+ Heart Failure and Diabetes
Recommendation
Thiazolidinediones (glitazones) cause sodium and water
retention and increased risk of worsening HF and
hospitalization and are not recommended in patients with HF.

Recently, empagliflozin, an inhibitor of sodium-glucose co-

transporter 2, reduced hospitalization for HF and mortality, but
not myocardial infarction or stroke, in patients with diabetes at
high cardiovascular risk, some of whom had HF.
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Prognosis
Despite many recent advances in the evaluation and
management of HF, the development of symptomatic HF still
carries a poor prognosis.

Community-based studies indicate that 3040% of patients die

within 1 year of diagnosis and 6070% die within 5 years, mainly
from worsening HF or as a sudden event (probably because of a
ventricular arrhythmia).

Patients with symptoms at rest (New York Heart Association

[NYHA] class IV) have a 3070% annual mortality rate, whereas
patients with symptoms with moderate activity (NYHA class II)
have an annual mortality rate of 510%. Thus, functional status is
an important predictor of patient outcome
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Thank You