Cor Pulmonal Chronic

Yanis Indiana Yacma

Preceptor :

dr. Nurkhalis, Sp.JP-FIHA

Case report

Laporan Kasus

Name : Tn.RSex : ManAge : 31 years oldReligion : IslamEthnic : AcehAdress : PidieOccupation : -No. RM : 1051747Date on arrival : 12 Mei 2015Date on examination: 5 Juni 2015

Anamnesis Chief complaint: DyspneuChief complaint: Dyspneu

Weak, cough, fever, chest pain

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. Itsn’t 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 cann’t 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 : brown, jaundice (-), cyanosis (-), edema (-)Head : hair normal distribution, it is difficult revokedFaces : symmetrical, edema (-), deformity (-)Eyes : anemic (+ / +), jaundice (- / -), secretions (- / -),

RCL (+ / -), RCTL (- / -), pupil isokor -/-Ears : normotia impression, secret (- / -)Nose : secret (- / -), hyperemia (-), NCH (-)Mouth : dry mucous (-), cyanosis (-)Neck : suprasternal retraction (-), lymphadenopathy (-),

stiff neck (-), TVJ: R+2 cmH2O.

• Skin : brown, jaundice (-), cyanosis (-), edema (-)Head : hair normal distribution, it is difficult revokedFaces : symmetrical, edema (-), deformity (-)Eyes : anemic (+ / +), jaundice (- / -), secretions (- / -),

RCL (+ / -), RCTL (- / -), pupil isokor -/-Ears : normotia impression, secret (- / -)Nose : secret (- / -), hyperemia (-), NCH (-)Mouth : dry mucous (-), cyanosis (-)Neck : suprasternal retraction (-), lymphadenopathy (-),

stiff neck (-), TVJ: R+2 cmH2O.

• Anterior thoracicInspection

Static : SymmetricDynamic : Asymmetric

Palpation : Left SF > right SF, tenderness (+/-), crepitus (- / -)

Percussion : Dim/ hypersonorAuscultation : Vesicular (- / +), rhonki (+ / +) 2/3 lower lung, wheezing (- / +)

• Anterior thoracicInspection

Static : SymmetricDynamic : Asymmetric

Palpation : Left SF > right SF, tenderness (+/-), crepitus (- / -)

Percussion : Dim/ hypersonorAuscultation : Vesicular (- / +), rhonki (+ / +) 2/3 lower lung, wheezing (- / +)

• Posterior thoracic• Inspection

• Static : symetris• Dinamic : Asymetris

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

(-/+)

• Posterior thoracic• Inspection

• Static : symetris• Dinamic : Asymetris

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

(-/+)

Heart◦ Inspection : ictus cordis not visible◦ Palpation : ictus cordis palpable in ICS IV, right

midcalivularis line.◦ Percussion : cardiac border

Up : ICS III left parasternal line Left : ICS V left parasternal line Right : ICS III right axillaris anterior line

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

Heart◦ Inspection : ictus cordis not visible◦ Palpation : ictus cordis palpable in ICS IV, right

midcalivularis line.◦ Percussion : cardiac border

Up : ICS III left parasternal line Left : ICS V left parasternal line Right : ICS III right axillaris anterior line

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

Abdomen◦ Inspectionsymetric, distension (-), collateral vein (-), scar (+)◦ Palpationorganomegaly (-), tenderness (-), defans muscular (-)◦ Percussiontimpani, shifting dullness (-), undulation (-)◦ Auscultationperistaltic normal

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

Abdomen◦ Inspectionsymetric, distension (-), collateral vein (-), scar (+)◦ Palpationorganomegaly (-), tenderness (-), defans muscular (-)◦ Percussiontimpani, shifting dullness (-), undulation (-)◦ Auscultationperistaltic normal

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

Table 2.4 Laboratory: Date 25-05-2015

Pemeriksaan Laboratorium Hasil Nilai Normal

Darah Rutin    

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 /µL 4,2-5,4 jt/ µL

Trombosit224.000 / mm3 150.000-450.000/mm3

Hitung Jenis    

Eosinofil 4 0-6

Basofil 1 0-2

Netrofil batang 0 0-1

Netrofil segmen 65 50-70

Limfosit 22 20-40

Monosit 8 2-8

Elektrolit    

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/LDiabetes    

Glukosa Darah Sewaktu<200 mg/dl

Ginjal-Hipertensi  

Ureum 13-43 mg/dl

Kreatinin 0,51-0,95 mg/dl

Table 2.4 Laboratory: Date 05-06-2015

Pemeriksaan Laboratorium Hasil Nilai Normal

Darah Rutin    

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 /µL 4,2-5,4 jt/ µL

Trombosit287.000 / mm3 150.000-450.000/mm3

Hitung Jenis    

Eosinofil 2 0-6

Basofil 0 0-2

Netrofil batang 0 0-1

Netrofil segmen 76 50-70

Limfosit 11 20-40

Monosit 11 2-8

Elektrolit    

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 90-110 mmol/L

Kalsium (Ca) 8,6-10,3 mg/dl

Ginjal-Hipertensi  

Ureum 13-43 mg/dl

Kreatinin 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

Conclusion:Old fracture clavicula dextra, destroyed lung, old TB.

Plain Photo examination thoraks

Working diagnosis

• Cor pulmonal chronic• Bronkiektasis with destroyed lung• Pneumonia

TherapyTherapy 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. ECHO2. Follow up ECG3. Blood gas analysis

Prognosis

Quo ad vitam : dubia ad malamQuo ad fungsionam : dubia ad malamQuo 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