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Introduction
Heart is a powerful pump made of muscle (myocardium). It is divided into four
chambers: the upper two atria are the receiving chambers and the lower two ventricles are the
pumping chambers.2
Dilated cardiomyopathy (DCM) causes the heart to become enlarged, particularly the
left ventricle, and to function (squeeze and pump) poorly. As a result, the heart muscle
becomes weak and thin and is unable to pump blood efficiently around the body. This causes
fluid to build up in the lungs, which become congested, and results in a feeling of
breathlessness. This condition is called "left heart failure." Often there is also right heart
failure, which causes fluid to accumulate in the tissues and organs of the body, usually the
legs and ankles, and the liver and abdomen.2
This is the most common form of cardiomyopathy and it affects about 6 per million
children each year. Dilated cardiomyopathy (DCM) occurs when disease affected muscle
fibers are enlarged or stretched (dilated) in one or more chambers of the heart. Usually, the
enlargement begins in one of the two lower pumping chambers (left ventricle) and then
proceeds to the heart's upper chambers (atria) as the condition progresses. Eventually over
time, all four of the heart's chambers are affected as the heart tries to "compensate" its
weakened condition and poor contraction by further stretching. A possible complication is
when the valves (mitral or tricuspid) between the upper chambers (atrium) and lower
chambers (ventricles) also enlarge. As the heart enlarges, it decreases its efficiency in
pumping blood through the body. When the disease progresses to congestive heart failure,
fluid can build up in the lungs, liver, abdomen and lower legs.1
The aim of the paper is to report a case of dilated cardiomyopathy in a 14 year girl.
CASE REPORT
Name
: AAM
Age
: 14years
Sex
: Female
Date of Admission
AAM, female, 14 years old, Indonesian, admitted to Haji Adam Malik General Hospital on
29th April 2014 with shortness of breath. She has been experiencing shortness of breath for
the past one month. Her condition has been worsen in this two weeks and related to activity.
She can get easily tired since 5 years old. She have history of continous fever and cough in
the past one month. She also have been experiencing joint pain in the last four month.
Decrease in body weight was found in this four months. The patient have been seen pale in
this four month and there is no bleeding found. History of constipation was found for two
days.
Before she was admitted to Adam Malik General Hospital, she was treated by a pediatrician
in Bunda Thambrin Hospital with dilated cardiomyopathy and minimal pulmonary embolus.
Later she was referred to Adam Malik General Hospital for further treatment.
History of previous illness
: Cardiomyopathy and minimal pulmonary embolus
History of previous medications : Propranolol, Aldactone, Digoxin
History of labor
: Normal delivery, cried as soon as baby was born, no
cyanosis
History of growth and
Development
: Growth and development when toddler
suitable with toddler in same age.
History of immunization
: complete immunization
Physical examination
Presens status
Sensorium
Temperature
Heart Rate
: Alert
: 37,5C
: 110 bpm, regular, murmur (-)
Respiratory Rate
Blood Pressure
Weight
Height
Nutrition Status
Anemic and dyspnea was found while cyanosis,icteric and edema were not found.
Localized Status
Skin
Pale
Head
Eyes
Nose
inferior (+/+)
Normal in appearance
Ear
Normal in appearance
Tounge/
Normal in appearance
Teeth
Tonsil/
Normal in appearance
Pharynx
Neck
Thorax
Abdomen
Extremitie
Pulse 110 bpm, regular, p/v was adequate, warm extremities, CRT <3
Genitalia
, normal in appearance.
Unit
g%
Result
11.6
Reference
12.0-14.4
Erythrocyte (RBC)
Leucocyte (WBC)
Hematocrite
Erythrocyte
sedimentation
106/mm3
103/mm3
%
mm/hou
4.54
5.240
35.1
23
4.75-4.85
4.5-11.0
36-42
0-20
rate
Thrombocyte (PLT)
MCV
MCH
MCHC
RDW
MPV
r
103/mm3
fl
pg
g%
%
fl
351
77.4
25.7
33.2
18.0
6.14
150-450
75-87
25-31
33-35
11.6-14.8
7.0-10.2
61.7
26.4
11.8
0.113
0.01
37-80
20-40
2-8
1-6
0-1
Difftel Count
Neutrophil
Lymphocyte
Monocyte
Eosinophil
Basophil
%
%
%
%
%
Neck
appearance.
Enlargement of lymph nodes (-)
Thorax
Abdomen
Extremities
not palpable
Pulse 108 bpm, regular, p/v was adequate, warm extremities, CRT
<3
BP: 90/70 mmHG hypotropy muscle (+), loss of subcutaneous fat
(+)
A : CHF ec dilated cardiomyopathy + moderate MR+ mild TR + minimal PE +
severe malnutrition.
P:
Neck
appearance.
Enlargement of lymph nodes (-)
Thorax
Abdomen
Extremities
Pulse 108 bpm, regular, p/v was adequate, warm extremities, CRT
<3
BP: 90/70 mmHG hypotropy muscle (+), loss of subcutaneous fat
(+)
A : : CHF ec dilated cardiomyopathy + moderate MR+ mild TR + minimal PE +
severe malnutrition.
P:
Neck
appearance.
Enlargement of lymph nodes (-)
Thorax
Abdomen
Extremities
Pulse 100 bpm, regular, p/v was adequate, warm extremities, CRT
<3
BP: 90/70 mmHG hypotropy muscle (+), loss of subcutaneous fat
(+)
A : : CHF ec dilated cardiomyopathy + moderate MR+ mild TR + minimal PE +
severe malnutrition..
P:
DISCUSSION
This case reported a 14 years old girl with dilated cardiomyopathy diagnosed based
on clinical features, chest x-ray and echocardiography. Dilated cardiomyopathy (DCM) is
diagnosed when the heart enlarged (dilated) and the pumping chambers contract poorly
(usually left side worse than right). This condition is the most common form of the
cardiomyopathy and accounts for approximately 55-60% of all childhood cardiomyopathies.
A chest X-ray will show the heart size and can be used as a reference to follow
increases in heart size that may occur over time. In this case, her chest X-ray shows there is
an increase in heart size and proven to be cardiomegaly.
The majority of children with DCM have signs and symptoms of heart failure. The
most common types of medications used to treat heart failure include diuretics, inotropic
agents, afterload reducing agents and beta-blockers. Diuretics, sometimes called water
pills, reduce excess fluid in the lungs or other organs by increasing urine production. The
loss of excess fluid reduces the workload of the heart, reduces swelling and helps children
breathe more easily. Diuretics can be given either orally or intravenously. Common diuretics
include furosemide, spironolactone, bumetanide and metolazone. Common side effects of
diuretics include dehydration and abnormalities in the blood chemistries (particularly
potassium loss). Patient in this case has been given with lasix injection with dosage 30mg for
12 hours through intravenous.
Inotropic Agents are used to help the heart contract more effectively. Inotropic
medications and are most commonly used intravenously to support children who have severe
heart failure and are not stable enough to be home. Common types of inotropic medications
include:3
Digoxin (taken by mouth): improves the contraction of the heart. Side effects include
low heart rate, and, with high blood levels, vomiting and abnormal heart rhythm.
Dobutamine, dopamine, epinephrine, norepinephrine (intravenous medications given
in the hospital): medications that increase blood pressure and the strength of heart
contractions. Side effects include increased heart rate, arrhythmias and for some,
sodium.
Milrinone (intravenous medication): improves heart contraction and decreases the
work of the heart by relaxing the arteries. Side effects include low blood pressure,
arrhythmias and headaches.
In this case, the patient have been treated with digoxin to improvethe contraction of her
heart.
Beta-blockers slow the heartbeat and reduce the work needed for contraction of the
heart muscle. Slowing down the heart rate can help to keep a weakened heart from
overworking. In this case, the patient had been given with propranolol. Side effects include
dizziness, low heart rate, low blood pressure, and, in some cases, fluid retention, fatigue,
impaired school performance and depression.3
Nutritional status in this patient based on the CDC curve for girls 2 20 years is
severe malnutrition, so this patient should be managed to improve his nutritional state. The
calories target for this patient, female, 14 years with body weight 28kg, body height 146 cm,
and height age 11 years is 1660 (RDA based on height age X ideal body weight). This patient
has managed by giving F75 250cc per 3 hours and 5cc of mineral mix.
Although some cases of dilated cardiomyopathy reverse with treatment of the
underlying disease, many progress inexorably to heart failure. With continued
decompensation, heart transplantation may be necessary.The prognosis for patients with heart
failure depends on several factors, with the etiology of disease being the primary factor. Other
factors play important roles in determining prognosis; for example, higher mortality rates are
associated with increased age, male sex, and severe CHF. Prognostic indices include the New
York Heart Association functional classification.The Framingham Heart Study found that
approximately 50% of patients diagnosed with CHF died within 5 years. [5] Patients with
severe heart failure have more than a 50% yearly mortality rate. Patients with mild heart
failure have significantly better prognoses, especially with optimal medical therapy. In the
this case, the patient have a poor prognosis.
SUMMARY
This paper reports about a 14 years old female diagnosed with dilated
cardiomyopathy. Diagnosis is made by clinical features, chest X-ray and echocardiography.
This patient is treated with furosemide, beta blockers and inotropic agents. Since dilated
cardiomyopathy can be chronic diseases, it is important for this patients to have good general
health practices to improve her quality of life, these include eating a well-balanced, nutritious
diet to restore and maintain muscle strength and endurance.
REFERENCE
1.
2.
2014]
https://www.bcm.edu/departments/pediatrics/cardiology/dilatedcardiomyopathy
3.
4.
5.
Mei 2014]
http://emedicine.medscape.com/article/984358-medication#3 [Accessed on 5th Mei
6.
2014]
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2064944/ [Accessed on 3rd Mei 2014]