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GRAND ROUND

September 10th 2015

CC I
NO

NAME

AGE

December 2015

DIAGNOSIS

Mr. Sp

57

CHF NYHA III ec CAD 3VD + on PPM +


Ascites + DM2

Mr. Rw

56

UAP KILLIP I TIMI 4/7 CAD 3VD + HT


stage II + DM tipe II + post PCI (sept
2015)

Mr. M

60

CHF NYHA III-IV ec severe MR,TR,PH +


A fib NVR + Hypertiroid

Mr. TD

60

ADHF pada CHF NYHA II ec OMI


anteroseptal + HT + dyslipidemia

Mr. PD

27

FEMALE WARD
NO

NAME

September 3rd 2015

AGE

DIAGNOSIS

Mrs. S

65

STEMI inferior

Mrs. Sl

54

CHF ec HHD

Mrs. SS

58

CHF ec HHD, MR, AF

Mrs. SR

60

Pro PAC standby PCI

CC I
NO

NAME

June 18th 2015


AGE

DIAGNOSIS

201 1

Mr. K

46

CHF NYHA II ec AR severe,


Possible IE

Mr. N

62

STEMI inferoposterior

202 1

Mr. S

62

CHF NYHA III ec susp IHD, DM,


efusi pleura duplex

2
203 1

CHF ec IHD, pro PCI


Mr. Sw

56

APS CCS II-III, pro PCI

65

CHF, recent STEMI anterior

204 1

Mrs. S

29

CHF NYHA III ec HHD, AF,


subclinical Hypertiroid

Mrs. N

56

CHF ec DCM, dyslipidemia

205 1

Mr. Sn

65

NSTEMI killip I

Mr. Z

44

STEMI extensive anterior,


history of ALO, post PCI

Diagnosis
NSTEMI
CHF NYHA II ec IHD
PCI history in March 2015
Hypertension st II
Dyslipidemia

Case ilustration
Patient identity
Name

: Mr S

Age

: 66 yo

Adress

: Besani RT 4/RW 1

Occupation

: Retired

Date of admission : September 7th 2015


Insurance

: BPJS non PBI

Recent history
Chief complaint : chest pain

March 27th 2015


Patient had PCI, 2
BAS in ramus
intermediate and 1
DES in LAD

3 hours before admission


Chest pain (+), felt like heavy pressure, radiating to neck an
left arm, 30 minutes duration, did not relieve with rest. Nausea
(+), Diaphoresis (+), Vomiting (-), Dyspnea (-), syncope (-).
Patient took ISDN sublingually, the pain decreased for a while,
but then pain came again. Patient went to RSDK
cardiovascular outpatient care facility

2 months before admission


DOE (+), OP (+), PND (+),
fatigue (+). Edema in lower
extremities (-).

At RSDK
Chest pain (+). Patient took
another ISDN sublingually. Pain
decreased a little in intensity.
Dyspnea (-), Palpitation (-),
syncope (-)

RISK FACTORS FOR CAD


Hypertensi
on

(+)

DM

(-)

Dyslipidemi (+)
a
PAST MEDICAL HISTORY
Gastritis

Asthma

Allergy

Stroke

Kidney disease

Alcohol abuse

Smoker

(-)

Family
history

(-)

Medication history

Miniaspi 80mg/24hour
Furosemide 40mg/24hour
Diltiazem 30mg/12hour
Clopisan 75mg/24hour
Simvastatin 10mg/24hour
Isonat 10mg/24hour
Spironolactone 25mg/24hour
Diovan 80mg/24hour

Family History
Hypertension (+)
There is no family member with
history of heart disease

PHYSICAL EXAMINATION
General Condition and Vital
Signs

Head and Neck


Pale conjunctiva

-/-

Level of
Composmentis
consciousne
ss

Icteric sclera

-/-

Cyanotic lips

(-)

JVP

R +2
cmH2O

Hepatojugular
reflux

GCS

E4V5M6

General
condition

Moderately ill

Weight

60 kg

Height

165 cm

BMI

22,03 kg/m2

BP

160/100 mmHg

HR

92x/mnt

RR

18x/mnt

Temp

36C

SaO2

99

PHYSICAL EXAMINATION
Chest
HEART
Inspection
IC can be seen on 5th ICS, 2
cm lateral to LMCS
Palpation
IC was palpated on 5th ICS, 2
cm lateral to LMCS
Auscultation
Normal S1, S2
Murmur (-)
Gallop (-)

LUNG
Inspection
Symmetric while in static &
dynamic state
Palpation
Equal stem fremitus in both
lung fields
Percussion
Sonor
Auscultation
Vesicular +/+
Rales +/+, minimal at lungs
base
Crackles -/ Wheezing -/-

PHYSICAL EXAMINATION
Abdomen
Inspection
Flat
Auscultation
Normal
Percussion
Dull in right upper quadrant, shifting dullnes (-)
Palpation
Liver can be palpated 2 cm below arcus costae
Extremities

Warm extremities
Edema -/Cyanotic -/Gastrocnemeus pain -/Clubbing finger -/-

DIAGNOSTIC STUDIES

ECG (September 7 2015,


09.38)
th

Sinus rhythm. 79x/menit. LAD. LAFB. LAE. Q patologis di V1-V4. ST


depresi di lead V5,V6

ECG (September 8th 2015, 07.00)

Sinus rhythm. 60x/menit. LAD. LAFB. LAE. Q patologis di V1-V5

Laboratorium
PEMERIKSAAN

HASIL

SATUAN

NILAI NORMAL

HEMATOLOGI (7/9 2015)


Hb

13,3

g/dL

12,00 15,00

Hct

37,2

35 47

Eri

4,11

106/L

4,4 5,9

MCH

32,3

pg

27,00 32,00

MCV

950,4

fL

76 96

MCHC

35,8

g/dL

29,00 36,00

Leu

5,59

103/L

3,6 11

Trom

245

103/L

150 400

RDW

11,3

11,60 14,80

MPV

6,55

fL

4,00 11,00

PEMERIKSAA

HASIL

HASIL

SATUAN

NILAI NORMAL

KIMIA KLINIK
Fasting

89

mg/dL 80 109
PEMERIKSAAN

Glucose
2h
PP

98

mg/dl

80-140

glucose
HbA1C

5,7

6-8

23
177

U/L
7-25
mg/dL <200

CKMB
Total

25

Choleste
91

mg/dl

<150

de
HDL C

48

mg/dl

40-60

LDL C

102

mg/dl

0-100

Uric acid

6,2

mg/dl

3,5-7,2

mg/dl

15-39

Ureum

24

HASIL

SATUAN

NILAI
NORMAL

Creatinine

1,0

mg/dL

Mg

0,97

mmol/L

0,74-

mmol/L

0,99
2,12-

mmol/L

2,52
136-

Ca
Na

rol
Triglyceri

HASIL

2,15
140

0,6-1,3

3,6

mmol/L

145
3,5-5,1

Cl

106

mmol/L

98-107

Troponin

0,1

0,0

mcg/L

<0,01

THERAPY

Bed Rest
Inf RL 8 tpm
Inj. Arixtra 2,5 mg/24 jam intravena
Inj. Cedocard syringe pump 2mg/jam intravena
Inj. Furosemid 20mg/12jam intravena
Aspilet 80mg/24 jam intravena
Clopidogrel 75 mg/24jam
Valsartan 80mg/24jam
Spironolactone 25mg/24jam
Lansoprazole 30mg/24jam
Simvastatin 20mg/24jam
Biscor 2,5mg/24jam

PROGRAM

Vital signs monitoring


Fluid balance /24 hour
ECG if patient feel chest pain
Echo
Chest X ray

THANK YOU

CTR 59%. Elongatio aorta (+). Cardiac waist (-). Apex laterocaudal.
Increase bronchovascular markings. Right and left Costophrenic
angle are not sharp.