Personal AssignmentGuidelines of Congestive Heart Failure in District Hospital

By:Diah Widowati0606103911

Supervisor:Prof.DR.Dr. Samsuridjal Djauzi SpPD-KAI(K)

Internal Medicine Clinical PracticeFaculty of Medicine University of Indonesia 2011

Originality Statement

This assignment is my own workAnd all the source cited or referencedIs stated to be original

Name:Diah WidowatiNPM:0606103911

Signature:Date:

Agreement Sheet

This assignment is made by:Name:Didi WidowatiNPM:0606103911Study Program:S1 Regular Program Faculty of MedicineTitle:Statement of Congestive Heart Failure in District Hospital

Agreed by:Supervisor,

Prof.DR.Dr. Samsuridjal Djauzi SpPD-KAI

In:JakartaDate:CONTENTORIGINALITY STATEMENTAGREEMENT SHEETCONTENTINTRODUCTION1.1 Background1.2 Problem Identification1.3 Aim1.3.1 General Aim1.3.2 Specific AimLiterature Review1.3.3 Pathogenesis of Congestive Heart Failure1.3.4 Diagnosis of Congestive Heart Failure1.3.5 Prevention of Congestive Heart Failure1.3.6 Guidelines of Congestive Heart Failure1.3.6.1 Nonpharmacologic treatment guidelines1.3.6.2 Pharmacologic treatment guidelines1.3.6.3 Tools and surgery guidelines1.3.6.4 Heart Failure GuildlinesCase IllustrationDiscussionConclusion and RecommendationWorks Cited

Chapter IINTRODUCTION1.1 BackgroundA research that find out the total patients who is hospitalized in five hospitals in Jakarta found out that there is an increase of inpatient caused by heart failure, and there is a large increase in the mortality of the hospitalization process. This research in the center of cardiovascular treatment shows that congestive heart failure is the main cause of treatment and rehospitalization, the patient of congestive heart failure in Indonesia is generally younger, have more severe symptomps and also fraction ejection that is low and diabetes, a different characteristic with patients from other country

Indonesia is one of the country with the highest number of diabetic patient. In the year of 2000, prevalence of diabetes patients in Indonesi reached 8.4 million peoples and it is predict to reach 21.3 million in the year of 2030.

The risk factor that is linked to diabetes are hypertension, coronary artery disease, hypertrophy of the left ventricle have a large deal in the development of heart failure. There are several patophisiology process that is linked to diabetes and insulin resistence symptomps, lkike the increase of symphatetic nervous system increase, dysfunction of endothelial system, and the usage of fatty acid by myocardium, that can increase the risk of heart failure.

A clinical study found out that we usually found congestive heart failure especially in the elderly. Framingham study shows that the incidence of heart failure for a year in the patients that is older than 45 are 7.2 cases for every 1000 men. Congestive heart failure that is marked with high mortalkity with inpatient frequency that is large and the decrease of the quality of live. Even though the guidelines for treating heart failure improved in recent years, the result of the research shows that half of the dead happened in the first 3 months of inpatient care

Currently, the prevalence of heart failure in Indonesia is 1-2% in populations that is bellow 55 years old and increase drastically to 10% in population older than 75%. Considering that the increase in morbidity in the case of congestive heart disease. In this assignment we will discuss the steps for handling congestive heart failure cases, that encompass diagnostic approach, prevention and the guidelines in level two hospitals.

Problems indentification How to handle congestive heart failureAims1.3.1 General Aim To know how to handle congestive heart failure In level two hospitals1.3.2 Specific Aim To understand the pathophysiology and diagnostic approach for congestive heart failure To know how to prevent congestive heart failure To know the guidelines of congestive heart failure in level two hospital

Chapter IVDiscussionPatients that are feeling unwell in their thorax area when cleaning one of the part of the hose, and it is felt continuously during breathing. Patients said that before the symptomps, he went to the market by walking and cleaned all of his house, but nowadays the patient felt that he felt unwell easily just by sweeping the floor. This shows the decrease of activity tolerance, but also the patient can still do limited physical activity. Patient does not experience the unwell feeling in the thorax area if sleeping and can sleep with one pillow, The patient also never been awaken because of the unwelness. Orthopnea and paroxysmal nocturnal dyspnea shows the symptomps of heart failure felt during rest. This condition is accordance to class 3 functional of New York Heart Association (NYHA) classification where the classification of functional class III there is different of the limit of activity that can disturb their works. The activity will run in the surface which is clear without exhibiting many symptompsThe main complain by the patient is the shortness of breath., This complaint in night or parixismal nocturnal dyspnea. PND is caused by the depression of the center area of respiration when they are sleeping, that cause the decrease in ventilation so there is a decrease in oxygen saturation especially in patients with lung edema interstisial. According to the location where dyspnea deffort, paroxsisimal nocturnal dyspnea and ortopnea, so the shortness of breath in the patient is likely to be caused by heart problem. Cardiac dyspnea can be found in patients that has increased pulmonal vein and accumulation of interstitial fluid.Activation of receptor in the lung can cause the increase of the amount of breathing and swallow breathing in the oxygen that is needed to the usage of muscle that helped the breathing process for the exchange of air because of the decrease of heart volume, this will cause inbalance that may cause the fatigue of breathing muscle and shortness of breath sensationIn the patients, beside we find paroksimal nocturnal dyspnea, orthopnoe and dyspnoe on effort. Beside that, the physical examination can found distention of neck vein, cardiomegaly, we ronchi in both of the lung. According to diagnostic criteria of Framingham which is, diagnosis of heart failure can be strengthened. The signs of fluid retention in this case which are the inferior extremity bilateral and pitting. Because patient fulfill the diagnostic criteria of Framingham that may cause the signs of fluid retention, patient can be diagnosed as having congestive heart failureOxygen is given as early guidelines, remembering that the patients have chief complain of shortness of breath. With edema in the inferior extremity that shows fluid retention, patient need diuretics, the first line drug in congestive heart failure. Patient will have the cardiac diet with 1900 kal, UMU fluid balance of 500 cc per day, restriction of fluid into 500 cc a day as a nonpharmacologic guidelines to decrease the congestion symptomps. For the pharmacologic guideline of Captopril 3x625 mg. The early dosage of captopril should be 6.25 mg consumed three times a day. The early dosage shoud be 6.25 mg. This can be felt not quiet right because patients already consumed captopril as antihypertensive drug since diagnosed 1 year ago, and until now, the blood pressure of the patient is not controlled well. In the giving of captopril, the concentration of serum electrolit, ureum, creatinin and blood pressure need to be evaluated, so we can plan the plan to check the electrolyte, ureum and blood creatinine level, and observation of blood pressure. We can say that ACE-I can be used to prevent remodeling of left ventricle, repair the symptomps and decrease the duration of inhouse stay, and increase the time for safety. Captopril can be said to be given in the lowest dosage then increased to reach the effective dosageDiuretic that can be given to the patient is Lasix that have furosemide function. Furosemid is a loop diuretic, a kind of diuretic drugs family that is very efficient in making diuresis and natriuresis. Before giving diuretic, the renal function and electrolyte of the serum must be checked. If the function of the renal is not good, the diuresis function cannot run well, so giving furosemide will be futile. Because giving furosemide can be hyoped to have diuresis natriuresis effect, the natrium level of the blood may decrease. The kalium level may also decrease, furosemide can be felt as the diuretic class of drug. Lasix 1x 40 mg iv can be given for decrease of congestive heart. For this case the restention of water can increase the effect of ACE-i. But, by beginning of ACE-I we can use diuretic by decreasing the level so we can not experience hypotension. Aldactone 1x25 mg po that is classified as diuretic hematkalium, can also be given to fight the effect of aldosterone, that will be very fast if we only give ACE-i. So, the antagonist of aldosterone can be said to be given to congestive heart falure patient NYHA class III-Iv with fraction of ejection bellow 35%, and using diuretic, ACE-I and beta blockers. So in this patient, giving aldactone is rationalPatient of heart failure should not be , so it can help the process of defecating we can give laxadine 3x Cl po laxadin can be given so it will not defecate too long that can cause increase of symphatetic nerve that can cause the increase of activation. Ascardia 1x80 mg can be given to the patient with heart failure and can be seen having high risk that is higher than tromnboemboly artery or vein. The decrease of left ventricle function decrease is causing the blood flow that is statis that cause the increase of risk the creation of thrombus. This can cause aspirin to be recommended to patient of heart failure with ischemic heart disease that cause myocardial infarc and cause dead. The patients is also given omeprazole 2x20 mg that can prevent irritation in the stomach that has effect in the aspirin. Ambroxol 3x CI can be given to decrease the sputum.

Chapter 5Conclussion and Recommendation5.1 ConclussionFemale, 55 years that came because of shortness of breath that is increasing in the frequency 1 day SMRS and is hospitalized with diagnosis of congestive heart failure fc III e.c. CAD dd/ HHD, CAP dd/ with pulmonary tuberculosis with secondary infection, and HT grade 1 with HHD.The guidelines for congestive heart failure that is given for the case in the literature review, that is caused diuretic and ACE-I for congestive heart failure stadium C. Giving the therapy for the patient anticipate the effectivity and the side effect, The guidelines of the patient can be seen as clinical guides based on laboratory evaluation, this will determine also the drug consumption compliance that is same before entering hospitalThe patients and the family participate in the guideline of congestive heart falure, This patients, especially the care provider can help the education of family and the patients regarding the giving of the patients, aim and giving medicine and it is important in restricting the fluid therapy and the calculation of patients urine.Heart failure Is seen as one of the main problem of healthcare, so we can do anamnesis and physical examination supported by laboratory examination, and other supporting laboratrium activity to support the diagnosisThe guidelines for this patient is according to level two hospital, which is cheaper, the drug is more simpler and easier to get5.2 Recommendaiton1.Every doctor must understand and understand algorithm the guidelines of heart failure congestive seeing this as a live threatening disease2.Every doctor in level two hospital usualy does not have the good facility to increase the vigilance of the possibility of having comorbidity in handling conestive heart failure