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Case Report

A 38-Year-Old Woman Came with Breathing Difficulty Since

3 Days before Admission

by :

Anna Karenina Permatasari Boer, S.Ked

Devyana Enggar Taslim, S.Ked
Preceptor :
Prof. Dr. H. Ali Ghanie, SpPD, K-KV



Case Report
A 38-Year-Old Woman Came with Breathing Difficulty Since

3 Days before Admission

by :

Anna Karenina Permatasari Boer, S.Ked

Devyana Enggar Taslim, S.Ked

Has been accepted and approved as one of the qualification in senior clerkship at Internal
Medicine Department Dr.Mohammad Hoesin Hospital Palembang on April 21st 2014 June 30th

Palembang, May 2014

Prof. Dr. H. Ali Ghanie, SpPD, K-KV


We as the author dedicate this case report entitled Patient Come with Shortness of
Breath to our family. We give thanks to Prof. Dr. H. Ali Ghanie, SpPD, K-KV as our advisor.
We are grateful that this case report can be finished according to the schedule.
The purpose of this case report is to explore about Heart Failure as one of the diseases
with high morbidity and mortality worldwide caused by its complication. We hope that this case
report will be useful for our colleagues in internal medicine action so that we can understand and
apply the adequate diagnosis and treatment for the patients. Last but not least we give thanks to
the contribution of every person in finishing this case report.

Palembang, May 2014



Breathing difficulty the most common reason for visiting a hospital accident and
emergency department. Difficulty in breathing (also known as shortness of breath,
breathlessness, or dyspnea) is caused by various mechanisms related to different problems in the
body. Shortness of breath has many causes affecting the breathing passages (ventilation),
diffusion, distribution and transport and kidney disease.
Sudden and unexpected breathlessness is most likely to be caused by many problems the
most common causes are a problem with your lungs or airways such as asthma (airway have
narrowed and will produce phlegm, can cause wheezing and cough), pneumonia (lung
inflammation, caused by an infection), Panic attack or anxiety (take rapid or deep breaths, known
as hyperventilating). Heart problem such as silent heart attack without experiencing all
the obvious symptoms, such as chest pain and overwhelming anxiety, Heart failure (means your
heart is having trouble pumping enough blood around your body, usually because the heart
muscle has become too weak or stiff to work properly. It leads to a build-up of water inside the
lungs, which makes breathing more difficult), Heart rate or rhythm such as atrial fibrillation (an
irregular and fast heart rate) or supraventricular tachycardia (regular and fast heart rate).
Heart failure is a complex clinical syndrome of symptoms and signs that suggest the
efficiency of the heart as a pump is impaired. It is caused by structural or functional
abnormalities of the heart. Heart failure (HF), often called congestive heart failure (CHF) or
congestive cardiac failure (CCF) occurs when the heart is unable to provide sufficient pump
action to maintain blood flow to meet the needs of the body. Heart failure can cause a number of
symptoms including shortness of breath, leg swelling, and exercise intolerance. Most heart
failure can be explained by well-recognized etiologic factors, though ostensibly healthy patients
may harbor risk factors for the later development of heart failure. A fundamental response to
myocardial injury or altered loading conditions includes "remodeling" of the heart, so that the
size, shape, and function of the affected chamber is grossly distorted. This is accompanied by a

constellation of biologic changes, best recognized in advanced cases of heart failure. These
multiple alterations may be primary or secondary events but, nonetheless, add importantly to the
morbidity and mortality of the patients.
Men have a higher incidence of heart failure, but the overall prevalence rate is similar in
both sexes, since women survive longer after the onset of heart failure. Women tend to be older
when diagnosed with heart failure (after menopause), they are more likely than men to have
diastolic dysfunction, and seem to experience a lower overall quality of life than men after
diagnosis. Heart failure is associated with significantly reduced physical and mental health,
resulting in a markedly decreased quality of life With the exception of heart failure caused by
reversible conditions; the condition usually worsens with time. Although some people survive
many years, progressive disease is associated with an overall annual mortality rate of 10%.
The most common causes of heart failure are Coronary Heart Disease (CHD) the
condition in which a waxy substance builds up inside the coronary arteries, High Blood Pressure
the force of blood pushing against the wall of the arteries, and Diabetes the blood glucose
level is too high. Treatment for the cancer such as radiotherapy and chemotherapy, thyroid
disorder, alcohol abuse or cocaine, HIV/AIDS, too much vitamin E also can injure the heart
muscle and lead to heart failure. NSAID and drugs for type 2 diabetes can also cause heart
attack, stroke, and hypertension if we used it for a long period of time.
Cardiac diseases are also common in pregnancy woman. The presence of cardiovascular
disease in pregnant women poses a difficult clinical scenario in which the responsibility of the
treating physician extends to the unborn fetus. Profound changes occur in the maternal
circulation that has the potential to adversely affect maternal and fetal health, especially in the
presence of underlying heart conditions. Up to 4% of pregnancies may have cardiovascular
complications despite no known prior disease.

2.1 Anamnesis (April 30th 2014)
2.1.1 General Data

: Mrs. NS


: Jln Pemugaran, Ogan


: Female


: Housewife


: 38 years old


: Moeslem

Marital status

: Married

Date of admission

: April 24th 2014

2.1.2 Chief complaint

Shortness of breath that becomes more severe since 1 day before admission and chest pain
radiate to the back.
2.1.3 History of Present illness
One and half months before admission, patient companied breathing difficulty, even during
light activity, felt more comfortable when rest and sit position. She also complained when the
womb become larger she feels like her chest being pushed. Cough (+) without sputum, fever (-),
nausea (-), vomiting (-). She took usual medicine and feel better and she routine control in clinic.
Three days before admission, patient complained breathing difficulty even when on activity,
felt more comfortable when sit position and rest with 2 pillows in piles. She also complained
chest pain radiate to the back part of the body and feel numbness at the right leg, Cough (-), fever
(-), nausea (-), vomiting (-). Patient feels weak. Swelling in leg (+), there is no problem with
2.1.4. Past History

First and second gestation was normal delivery without any complication
History of high blood pressure since 3rd gestation
History of diabetes mellitus denied
History of asthma is denied
History wound doesnt heal is denied

No infectious history
No allergic history

2.1.5. Family History

History of hypertension (+)

History of diabetes mellitus (-)

2.2 Physical examination (April 30th 2014)

a. vital sign

Temperature: 37.10C, Pulse: 96/min, RR: 40x/min, BP: 160/80mmHg

b. General Appearance
: moderately sick
: compos mentis (aware)
facial feature
: acute pain
: painful
: semi recumbent
: well
c. Skin and Mucosa
: white yellowish, normal pigmentation
: no lesion
subcutaneous hemorrhage
: no subcutaneous hemorrhage
: normal
moisture and temperature
: normal
: normal
: edema at face and feet
hepatic palm
: no hepatic palm
spider angioma
: no spider angioma
d. Specific Examination:
superficial lymph node:
submandibular, neck, subclavicula, and axillaries lymph nodes
Cranium size normal, no deformity, no hair loss, tenderness (-)
Auricle normal, no excretion of external canal, no tenderness in mastoid area
Normal shape, no nasal sinus tenderness

Normal eyelid, normal eyeballs, conjunctiva normal, sclera ikteric (-), pupils

equal roundness, reaction to light normal

Red lips, normal mucosa, normal tongue, normal gums, regular tooth, normal

tonsil, normal voice

No resistance, increase carotid artery pulsation, jugular vein (5-2)cm H2O,

hepatojugular reflux (-), trachea (middle), normal thyroid

normal topography, no tenderness of sternum, normal breast (symmetrical),
i. I : static: symmetric; dynamic : same movement right and left, retraction(-)
ii. P : stem fremitus same right and left, pleural friction rubs (-), tenderness
iii. P : sonor (resonance) on left and right lung

iv. Breath regular, breath sound normal, rales (-), ronki (-)
o Frequency
: 22x/minute
o Rhythm
: regular
o Type
: toraco-abdominal
i. I: bulging in precordial (-), apex impuls (-), position of apex normal, other
precordial pulsation (-)
ii. P: apex impulse normal, thrills (-), precardial friction rub (-)
iii. P: relative cardiac outline normal, top border of cordis left ICS II, right
border of cordis linea midclavicula dextra, left border of cordis linea
axillary anterior sinistra
iv. A: HR: 100bpm, rhythm regular, heart sound normal, extra sound (-),

murmur (-), precardial friction rub (-), peripheral vessel (n)

i. I: shape (n), collateral vein (-), striae (+), abdominal respiration (n),
umbilicus (n)
ii. P: soft, liver, spleen, kidney and gallbladder cannot be touch, tenderness

(-), masses (-)

iii. P: cannot be percussion, because she is pregnant
iv. A: bowel sound normal, vessel bruit (-)
Genitalia : not examined
Rectum and anus : not examined

Spine and extremities:

o Spine : normal
o Extremities :
upper: pain joint (-), palmar erythema (+), clubbing finger (-).
Lower: varices (-), tibial edema(-), dorsum pedis edema (-)
Nerve system
o Muscle tone (n), physiological reflex (n), pathological reflex (-)
: picnicus
Body weight
: 60 kg
Body height
: 155 cm


: 24,9 kg/

2.3 Additional examination

a. Laboratory finding
Hematology (April 24th 2014)

: 11,1 g/dL (11,7-15,5)


: 3.240.000/mm3 (4.200.000-4.870.000)

Hematocryte : 31 % (38-44)

: 304.000/L (150.000-450.000)

Diff. Count


: 0 (0-1)


: 2 (1-6)

Neutrofil rod

: 1 (2-6)

Neutrofil segmen : 75 (50-70)


: 15 (25-40)


: 7 ( 2-4)


: 18300/mm3 (4.500-11.000)

Blood Chemistry (April 24th 2014)


: 77 mg/dL (< 200 mg/dL)


: 5 mg/dL (16.6-48.5)


: 0.46 mg/dL (0.50-0.90)


: 143 mEq/L (135-155)


: 2.2 mEq/L (3.6-5.5)

Liver (April 24th 2014)


: 16 U/L (0-32)


: 9 U/L (0-31)

Total bilirubin

: 0.31 mg/dL (0.1-1.0)

Direct bilirubin : 0.16 mg/dL (0-0.2)

Indirect bilirubin : 0.15 mg/dL (<0.8)
b. Electrocardiography

c. Other additional examination (planning)

Remeasurement Na, K
Anti HbsAg, anti HCV, anti HIV, VDRL/TPHA
USG kidney
Biopsy kidney
Lipid profile

A 38-year-old woman came to hospital with breathing difficulty that become more severe
since 3 days before admission. Patient have a history of hypertension since 3 years ago.
One and half months before admission, patient complained swelling whole body (leg,
arm, and eye). Shortness of breath (+), especially on activity, comfortable at rest, but ordinary
physical activity results in fatigue and dyspnea, shortness of breath was not influenced by
emotions. Fever (+), nausea (-), vomiting (-). Patient taken a medication to internist and the
symptoms didnt decreased.
One month before admission, patient complained the swelling whole body (leg, stomach,
arm, and leg) didnt decreased. Shortness of breath (+), marked limitation of physical activity,
comfortable at rest, but less than ordinary activity causes fatigue or dyspnea.
Since 3 days before admission, patient complained shortness of breath. Shortness of breath
occurs continuously. Patient unable to carry out any physical activity without discomfort.
Sometimes, patient waking up in midnight because of shortness of breath and sometimes patient
cannot sleep caused by shortness of breath. She was comfortable in sitting position or sleep with
2 pillows in piles. Her amount of urine was slightly, tea-colored urine. Patient feels weak and
pale. Sweeling in leg (+), Itch (+). Symptoms become more severe 1 day before admission.
From physical examination, pale of conjunctiva palpebrae (+), rales in base of lung (+),
ascites (+), edema pretibial (+). From laboratory examination, there is decreased Hb (11,1 mg/dl)
and Ht (31), increases leucocyte (18300), decreases ureum (5).

2.4 Working Diagnosis

Hypertension heart disease NYHA III + controlled hypertension
2.5 Differential Diagnosis
PPHD NYHA III + controlled hypertension
2.6 Treatment
Non pharmacology :

Bed rest semi recumbent

Oksigen 4L
Diet ??
o Eat healthy food
o Regular exercise
o Educate family member to support
o Educate about the disease, complication, and prevention


IVFD NaCl gtt xx/minute + Biknat flash (drip) (micro)

Injection furesemide 1x40 mg
Injection ceftriaxone 2x1 gram
Asam folat 3x1 mg
Methyldopa 3x250 mg

2.8 Prognosis

Quo ad vitam : dubia ad bonam

Quo ad funvtionam : dubia ad malam
Quo ad sanationam : dubia ad bonam



Difficulty in breathing (also known as shortness of breath, breathlessness, or dyspnea) is
caused by various mechanisms related to different problems in the body. Shortness of breath
has many causes affecting the breathing passages (ventilation), diffusion, distribution,
Heart failure can cause a number of symptoms including shortness of breath, leg
swelling, and exercise intolerance. Common causes of heart failure include myocardial
infarction (heart attack) and other forms of coronary artery disease, hypertension, valvular
heart disease, and cardiomyopathy. The term heart failure is sometimes incorrectly used for
myocardial infarction (which may cause heart failure, but is not heart failure in itself) or for
cardiac arrest (in which blood flow effectively stops altogether).
Fail of distribution process can be also cause shortness of breath. Distribution process is
depending on heart as a pumper blood to the whole body. If there any abnormality at the
heart, the heart cannot distribute the normal blood volume (decrease or increase). The
shortness of breath in heart failure caused by the decrease ability of the heart to fill and
empty, then producing elevated pressures in the blood vessels around the lung. The most
specific symptoms of the heart failure is feel breathing difficulty when lying down, the other
symptoms: necessity of propping up the head of the bed with many pillows, wakefulness at
night with shortness of breath, cough at night or when lying down, shortness of breath with
activity, swelling of ankles or legs, unusual fatigue with activity, and fluid weight gain

In this case, the patient do not complaint inadvertent foreign object. From the anamnesis
10 hours ago she felt breath difficulty (+) even during slight activity, but still not comfortable

at rest. So we can exclude the shortness of breath that caused by cold weather or exposure to
irritants. The shortness of breath was not accompanied by wheezing. So we can exclude the
problem from inflammation breathing passage. We knew that the patient felt difficulty when
laid down, the patient prefer used 2 pillows to lift up her head. We found that the
hepatojugular reflex (5+2)cm, from the ECG we found sinus tachycardia and left ventricular
hypertrophy with ST-T change (-), LV strain (+), PR interval 0.16s, QRS at V1 <1, Rv5-v6 +
Sv1 <35, axis (N), HR= 110x/min. So the shortness of breath in this patient maybe cause by
distribution problem (heart).
In this case, patient also did not complained that she had shortness of breath with
coughing, she felt more breath difficult and her chest like being push when her womb
become larger, murmur (-), gallop (-), pitting edema (-), elevated blood pressure (+).

3.2 Congenital Heart Failure

Heart failure is a clinical syndrome characterized by impaired structure and/or function
of the heart, leading to dyspnea and fatigue at rest or with exertion. A fundamental response
to myocardial injury or altered loading conditions includes "remodeling" of the heart, so that
the size, shape, and function of the affected chamber is grossly distorted. This is
accompanied by a constellation of biologic changes, best recognized in advanced cases of
heart failure. These multiple alterations may be primary or secondary events but, nonetheless,
add importantly to the morbidity and mortality of the patients

Criteria: Major (Heart Failure diagnosis requires 1 or more criteria positive)

Acute pulmonary edema
Hepatojugular reflex
Neck vein distention
Paroxysmal nocturnal Dyspnea or Orthopnea
Pulmonary rales
Third Heart Sound (S3 Gallup Rhythm)
Criteria: Minor (Heart Failure diagnosis requires 2 or more criteria positive)
Ankle edema
Dyspnea on exertion
Nocturnal cough
Pleural Effusion
Tachycardia (Heart Rate >120 beats per minute)
Heart Failure diagnosis requires 1 major criteria and 2 minor criteria
In this case, from the anamnesis we knew that the patient felt breathing difficulty when
she lying down or take a sit for a long time. The patient needs to prop her head with 2 pillows
when she lying down. The patient also feels breath difficulty during light activity. The patient
also complains that her face swelling and her feet are edema. From the examination we found
that she has cardiac enlargement. So, its fulfill 2 major criteria and 2 minor criteria, so this
patient we can called that she suffered from congestive heart failure.

3.2 Hypertension Heart Disease

Classification of blood pressure




<120 mmHg

<80 mmHg

Pre- hypertension

120-139 mmHg

80-89 mmHg

Hypertension stage I

140-159 mmHg

90-99 mmHg

Hypertension stage II

160 mmHg

100 mmHg

In this case, the blood pressure is 160/80mmHg. This is we can see as hypertension
stage II. These patients parents also have hypertension, from the father and mother.

3.3 PPCD (Peripartum Cardiomyopathy)

Peripartum cardiomyopathy (PPCM) is a form of dilated cardiomyopathy that is
defined as deterioration in cardiac function presenting typically between the last month of
pregnancy and up to five months postpartum. .[1][2][3][4][5]
PPCM is a diagnosis of exclusion, wherein patients have no prior history of heart
disease and there are no other known possible causes of heart failure.[1][2][3][4][5]
The cause of PPCM is unknown. Currently, researchers are investigating cardiotropic
viruses, autoimmunity or immune system dysfunction, other toxins that serve as triggers to
immune system dysfunction, micronutrient or trace mineral deficiencies, and genetics as
possible components that contribute to or cause the development of PPCM.[1][3][6]
Symptoms usually include one or more of the following: orthopnea (difficulty
breathing while lying flat), dyspnea (shortness of breath on exertion), pitting edema
(swelling), cough, frequent night-time urination, excessive weight gain during the last
month of pregnancy (1-2+ kg/week; two to four or more pounds per week), palpitations
(sensation of racing heart-rate, skipping beats, long pauses between beats, or fluttering), and
chest pain.[1][3]
The shortness of breath is often described by PPCM patients as the inability to take a
deep or full breath or to get enough air into the lungs. Also, patients often describe the need
to prop themselves up overnight by using two or more pillows in order to breathe better.
These symptoms, swelling, and/or cough may be indications of pulmonary edema (fluid in
the lungs) resulting from acute heart failure and PPCM.

Some studies assert that PPCM may be slightly more prevalent among older women
who have had higher numbers of live born children and among women of older and younger
extremes of childbearing age.[8][21] However, a quarter to a third of PPCM patients are young
women who have given birth for the first time.[2][3][8][17][22][23]
In short, PPCM can occur in any woman of any racial background, at any age during
reproductive years, and in any pregnancy.[18]
In this case,

Pearson GD, Veille JC, Rahimtoola S, et al. (March 2000). "Peripartum cardiomyopathy:
National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of
Health) workshop recommendations and review". JAMA 283 (9): 11838.
doi:10.1001/jama.283.9.1183. PMID 10703781.
Elkayam U, Akhter MW, Singh H, et al. (April 2005). "Pregnancy-associated
cardiomyopathy: clinical characteristics and a comparison between early and late presentation".
Circulation 111 (16): 20505. doi:10.1161/01.CIR.0000162478.36652.7E. PMID 15851613.
Sliwa K, Fett J, Elkayam U (August 2006). "Peripartum cardiomyopathy". Lancet 368
(9536): 68793. doi:10.1016/S0140-6736(06)69253-2. PMID 16920474.
Murali S, Baldisseri MR (October 2005). "Peripartum cardiomyopathy". Crit. Care Med. 33
(10 Suppl): S3406. doi:10.1097/01.CCM.0000183500.47273.8E. PMID 16215357.

Phillips SD, Warnes CA (2004). "Peripartum Cardiomyopathy: Current Therapeutic

Perspectives". Curr Treat Options Cardiovasc Med 6 (6): 481488. doi:10.1007/s11936-0040005-8. PMID 15496265.
Sliwa K, Frster O, Libhaber E, et al. (February 2006). "Peripartum cardiomyopathy:
inflammatory markers as predictors of outcome in 100 prospectively studied patients". Eur.
Heart J. 27 (4): 4416. doi:10.1093/eurheartj/ehi481. PMID 16143707.
Sliwa K, Skudicky D, Bergemann A, Candy G, Puren A, Sareli P (March 2000). "Peripartum
cardiomyopathy: analysis of clinical outcome, left ventricular function, plasma levels of
cytokines and Fas/APO-1". J. Am. Coll. Cardiol. 35 (3): 7015. doi:10.1016/S07351097(99)00624-5. PMID 10716473.