This document presents the case of an 18-year-old male patient admitted to the internal medicine ward for generalized body swelling and shortness of breath. His medical history includes pulmonary tuberculosis treated for 4 months and previous admissions for kalazar. On examination, he had elevated jugular venous pressure and edema. Initial tests showed renal and liver dysfunction. He was treated with antibiotics and diuretics. The case discussion provides background on heart failure definitions, classifications, etiologies, and treatment guidelines.

1. Morning case presentation
By Derso bewket (Idno_6083/07)
1
8/27/2019

2. Outline
2
• Socio-Demographic Data
• Clinical History
• Physical examination
• Investigation data
• Medication
• Pharmaceutical care plan
• Disease background
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3. IDENTIFICATION 3
 Name M.Z
Age 18 years old
Sex M
Card no. 832824
 Bed no. 13
 Address Dabat
 Admitted to the Internal medicine ward-D on 10/11/11
Patient stay 27 days
Ethnic origin ƒAmhara
Religion ƒorthodox
Occupation farmer 8/27/2019

4. Clinical History 4
Previous Admissions
November , 2011E.C, private clinic diagnosis pulmonary
tuberculosis and kalazar at shedy hospital
Chief complaints:- (general body swelling )GBS of 1
month duration
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5. HISTORY OF PRESENT ILLNESS 5
• This is 18 years old known TB patient for the last 2 month and 10 days
on anti TB medication
• Currently presented with GBS of 1 month duration the GBS started
from bilateral legs and gradually presented to abdomen. it associated
with easy fatigability during the normal activates.
• The patient also have SOB, orthopenea of of 02-03 pillows in the last
01 month
• The patient was having cough for the past 04 month productive blood
tingled sputum, night sweating , loss of appetite significant but un
quantified weight loss for which he was treated with anti TB
medication pas 04 month 8/27/2019

6. Cont… 6
• He has no Hx of contact with chronic cougher or Known TB patient
• He has no Hx of self /family Hx of HTN,DM
Past medical histories:- he has Hx of TB, kalazar& malaria epidemic area
Past medication histories :-
He has hx of kalazar treatment novmber 2011 at shedy hospital
Has hx of anti TB treatment 04 month back
Family histories:-there is no family Hx of TB, HTN,DM
Social histories:- he has alcohol drinker
Allargic histories :- there is no drug and food allergies
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7. Physical Diagnosis At admission 7
 G/A=ASL
V/S BP=110/70mmHg PR=100 RR=28 SO2= 100%
HEENT=pink conjunctive
LGS=no lephadnopathy
Respiratory =there is BBS heard over the right middle third of lung field
= decrease air entry over the left posterior 1/3of lung field
CVS= S1&S2are well heard
=JVP raise
Abd= full Abd move with respiration
 GUS= NO CVAT
 MSS= GII peating edema
IGI = no rash and pallor
CNS=conscious &oriented 8/27/2019

8. • Assessment NYHA class IV stage c 2o to DCMP with sever LV systolic
dysfunction(EF 15%)+ SCAP
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8

9. v/s
BP PR RR Tem so2
At admission 110/70 100 28 100%
16/11/11 100/70 92 22 36 95
18/11/11 110/80 87 21 36.5 94who
2211/11 100/60 96 23 36 95
24/11/11 100/60 92 24 36 94
25/11/11 >> 94 23 >> -
26/11/11 100/70 92 22 36.5 -
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10. Investigation
• 10/11/11
RBS 79mg/dl
U/A PH 6 5-8
Spg 1.030
Blood +3
Others NEG
 11/11/11
 Cr 0.75 0.6-1.1
Na 147 136-145mmol/l
K 5.34 3.5-5.1mmol/l
Chest X-ray cardiomegally with pulmonary arterial hypertension
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11. • 14/11/11
• Urea 93.73 16-48mg/dl
• Cr 1.48 0.6-1.1mg/dl
• SGOT 176.66 up to 32u/l
• SGPT 29.45 up to 31u/l
• BIIL T 5.82 up to 1mg/dl
• BILL D 4.45 up to 0.25mg/dl
• Serum protein 5.32 6.4-8.3g/dl
• Na 141 136-145mmol/l
• K 4.7 3.5-5.5mmol/l
• Cl 110 101-110mmol/l
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12. CBC
14/11/11
normal range level
• WBC 14.8 3.5-10x103/mm3 High
• RBC 6.12 3.8-5.8x106/mm3 High
• Hgb 12.2 11-18g/dl
• Hct 43 35-50%
• Plt 277 150-400
• Pct 0.176 0.1-0.5
• MCV 70 80-97fl low
• MCH 19.9 26.5-33.5 low
• MCHC 28.4 31.5-35g/dl low
• RDW 18.5 10-15 high
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13. Cont…
• %Lym 17.7% 17-49%
• %Mon3.5% 4-10% low
• %Gra 78.8% 43-76% high
16/11/11
Na 142 136-145mmol/l
K 2.7 3.5-5.1 low
SGOT 82 0-37u/l high
SGPT 54 0-47u/l high
Cr 0.72 0.6-1.1mg/dl
Cl 102 98-108
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14. 20/11/11 22/11/11
• SGOT 74 high K 4.46
• SGPT 59 high Na 143.9
• BILLD 1.29(1.5 Cl 106.9
• BILLT ica 1.46(1.1-1.4) H
• TP 5.7 Tca 2.86(2.2-2.9)
Ph 8(5-8)
SGOT 49 H
SGPT 39
BILLD 1.52mg/dl
TP 6.2G/dl
alb 0.87g/dl
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15. Other diagnosis
15/11/11
• HCV NEG
• HbsAG NEG
9/11/11
Echo ST-Segment elevation on V1-V2
-T wave inversion on V2-V3
13/11/11
PICT NR
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16. Treatment
At admission
Vancomycin 1g iv bid
Ceftraxon 1g iv bid
Doxycline 100mg po bid
Dopamine20ug/kg
Omeprazole 20mg po bid
Hold anti TB
Digoxin 0.25mg iv loading then 0.125mg po/day
Lasix 20mg iv stat
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17. Cont…
Revised order 14/11/11
• Vancomycin 1g iv every other day (48hr)
• Dopamin 15ug/kg
• The rest same the previous data
15/11/11
Hold dopamine
Hold lasix
Added KCL60meqin 500ml NS
17/11/11 Lasix 20mg po
D/c Doxyclin
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18. Cont…
19/11/11 Revised order
• Vancomycin 1g iv bid
• Ceftraxon 1g iv bid
• Lasix 40mg iv bid
• Digoxin 0.125mg po/day
• Spirnolactone 25mg po/day
• Enalapril 2.5mg poBID
• KCL 60meqiv in500ml NS run over Q8hr 22dpm
20/11/11 Added order
• Added KCL 40meq iv in 500ml NS
23/11/11
D/c antibiotics
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19. Currently revised order
• Lasix 40mg iv bid
• Enalapril 5mg po bid
• Metoprolol succinate 25mg po/day
• Spironolacton 25mgpo/day
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20. Pharmaceutical care plan
Goal of therapy:
• To alleviate all symptoms(SOB, orthopenea , GBS) and improve quality
of life
• To Prevent further complications
• To decrease death and hospitalization
• To Improve survival
• Treat the precipitating cause
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21. Monitoring parameter
• Vital sign
• CBC
• Organ function test
 lever function test
 Renal function test
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22. Un necessary drug's
Doxycline not used fore SCAP
Addational drug therapy macrolid nessray
DTP
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23. 23
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24. Definition
• Heart Failure is an abnormality of cardiac structure or function leading to failure of the
cardiac output to meet the body's metabolic requirements despite normal filling pressures.
• Clinically it is a syndrome consisting of typical symptoms (shortness of breath, fatigue,
orthopnea, ankle swelling) and signs (raised JVP, pulmonary crackles, displaced apex beat,
edem
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25. Form(type) of heart failure
 Systolic(with out) vs Diastolic(with reserved EF
 Left vs Right
 High output Vs Low output
 Acute Vs Chronic
 Forward Vs Backward
 Congenital vs Aquired
 Refractory vs Non refractory
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26. • Systolic heart failure:- HF due to abnormalities in cardiac
contractility.
• HF with depressed EF (systolic HF) EF<40%
 Diastolic heart failure:- HF due to impaired cardiac relaxation or
abnormal ventricular filling.
 HF with preserved EF (Diastolic HF)EF>40-50%
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27. Etiology 27
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28. Etiology
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29. 29
NYHA heart failure classification
Class Patient Symptoms
I No limitation of physical activity. Ordinary physical activity does not cause undue
fatigue, palpitation, dyspnea (shortness of breath).
II Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity
results in fatigue, palpitation, dyspnea (shortness of breath).
III Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity
causes fatigue, palpitation, or dyspnea.
IV Unable to carry on any physical activity without discomfort. Symptoms of heart failure
at rest. If any physical activity is undertaken, discomfort increases.8/27/2019

30. • Stage A — High risk for HF, without structural heart disease or
symptoms
• Stage B — Heart disease with asymptomatic left ventricular
dysfunction
• Stage C — Prior or current symptoms of HF
• Stage D — Advanced heart disease and severely symptomatic or
refractory HF
30stages of HF
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31. Investigation
 CBC, UA, OFT(LFT, RFT and TFT),Electrolyte, Glucose, lipid
profile, BNP, cardiac markers
 CXR, ECG, ECHO
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32. H =Hypertension
E=Endocarditis
A=Anemia
R=Rheumatic fever
T=Thyrotoxicosis
F=Fever
A=Arrhythmia
I =Ischemia
L=Lung infection
S=Stress (emotional, physical, dietary…)
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Precipitant factor

33. Non pharmacologic
• Reduce salt intake, avoid salt intake of >6g/day
• Avoid “salt replacement” tablets due to their high potassium content.
• Encourage patients to weigh themselves
• Reduction of weight in overweight and obese individuals
• Refraining from excessive alcohol consumption
• Avoid smoking. Patients should be offered smoking cessation advice
and support.
• Encourage low intensity physical activity amongst patients with
stable Heart Failure - Bed rest in hospitalized patients.
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34. Pharmacology
Initial therapy of severe Heart Failure (NYHA CLASS IV)
 Furosemide, 40mg iv
Add KCl 600mg, 1-2 tabs, twice per day or Spironolactone 25-50mg,
BID, if there is no renal impairment or hyperkalemia
ACE inhibtors or ARBS
N.B. Do not start ACE inhibitors/Angiotensin Receptor
Blockers until the patient is haemodynamically stable. For
patients with Left ventricular systolic dysfunction. Start with
low dose and increase gradually.
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35. Cont…
Beta blockers –
N.B. Beta blockers – should not be started in the acute management of
decompensated Heart Failure . After patient stabilization, beta
blockers can be started during discharge or as an out patient
management. Start with low dose and escalate gradually.
Digoxin, 0.125 mg once, P.O, daily
Dopamine, I.V infusion 1-5 ug /kg/minute up to 50 ug /kg/minute;
increase by 1- 4mcg/kg/minute at 10-to 30-minute intervals until
optimal response is obtained
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36. Reference
• Patient chart and pt interview
• Ethiopian standard treatment guideline 2014
• Uptodate 21.6
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37. 37
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