CASE BASED

DISCUSSION
Mega Puspita S

Advisor :
dr. H. M. Saugi Abduh, Sp. PD., KKV, FINASIM
PATIENT IDENTITY

◈ Name : Mr. S ◈ Address : Kedungwungu Karangsono

◈ Age : 48 years old Semarang
◈ Gender : Male ◈ MR number : 01344105
◈ Religion : Moslem ◈ Room : Izza 2/ M3
◈ Job : Farmer ◈ Entry date : March 2nd, 2018
◈ Date out : March 6th, 2018

2
 HISTORY TAKING
CHIEF COMPLAINT ◈ Chest Pain
Patient came into the emergency department in Islamic Hospital of Sultan
HISTORY TAKING Agung Semarang complained that he felt chest pain. The pain localized on
his left chest and radiate to his back. He felt the chest pain since 5 days
before he came to emergency room. He felt sharp chest pain and chest
discomfort. At the first he felt his chest pain comes and goes, his chest pain
eased when he took a rest and worsening when he did activity, but 1 day
before he came to hospital he felt chest pain all the day, chest pain not
relieved when he took a rest. He also complaint about dispnea. His dispnea
eased when he sit down and worsening when he lied down. He also felt
palpitate, sweating when he felt chest pain dan bloated. Abdominal pain,
nausea and vomit denied. He is a heavy smoker on average, he has around 30
3
cigarettes a day and he also regulary drinking coffee almost everyday.
 SISTEMIC ANAMNESIS
Chief Complains : Chest pain
Onset : 5 days ago
Location : Left chest
Chronology : He felt the chest pain since 5 days before he came to
emergency room. At the first he felt his chest pain comes
and goes, his chest pain eased when he took a rest and
worsening when he did activity, but 1 day before he came
to hospital he felt chest pain all the day, chest pain not
relieved when he took a rest.
Quality : He felt sharp chest pain and
chest discomfort.

4
 SISTEMIC ANAMNESIS

Quantity : He felt chest pain all the day, chest pain not
relieved when he took a rest
Modification factor : Better when he took a rest
Comorbid complains : Dispnea, palpitate, sweating when he felt
chest pain dan bloated.

5
 History of previous  History of family disease
disease o Asthma history (-)
o Asthma history (-) o Hypertension history (+)
o Hypertension history (+) o DM history (+)
o DM history (-)
o Heart disease history (-)  Socio-economic history
o Gastritis (-) Hospital cost not covered by
o Allergy (-) any health insurance

6
 PHYSICAL EXAMINATION

1. VITAL SIGN

VITAL SIGN

BP HR RR
151/108 SPO2 Temperature
78x 22x
mmHg 99 % 36,7°C
/minute /minute

Hipertension Grade I

7
 PHYSICAL EXAMINATION

2. GENERAL STATUS

BMI (Body Mass Indeks)

Weight : 72 kg
Height : 165 cm
BMI= 26,4 kg/m2
Overweight Pre-
obesitas

8
 PHYSICAL EXAMINATION

2. GENERAL STATUS
GENERAL WEAKNESS

AWARENESS Composmentis

HEAD Mesocephal, alopesia (-)

EYES Anemic Conjuntiva (-/-), Icteric sclera (-/-)

NOSES Symmetric, secret (-), Nostril Breath (-) Normal

9
 PHYSICAL EXAMINATION

2. GENERAL STATUS
EARS Normal Shape, Discharge (-/-)

ESOPHAGUS Hyperemic (-), Pain devour (-)

MOUTH Cyanosis (-), Dry lips (-), Stomatitis angularis (-)

NECK Trakhea deviation (-), Lymph Hypertropy (-),

Increaing jugular vein pressure (-)
Normal
EXTREMITY Oedem of lower extremity (-)
10
 PHYSICAL EXAMINATION
3. LUNG EXAMINATION
INSPEKSI ANTERIOR POSTERIOR

RR : 22x/min, Hyperpigmentasion (- RR : 22x/min, Hyper

), spider nevi (-), atrophy Pectoral pigmentasion (-),spider nevi (-),
Static
Muscle (-), Hemithoraks D=S, ICS Hemithoraks D=S,
Normal, Diameter AP < LL ICS Normal, Diameter AP < LL

Dynamic Up and down of hemitoraks

Up and down of hemitoraks D=S,
D=S, abdominothorakal
abdominothorakal breathing, (-),
breathing (-), muscle retraction
muscle retraction of breathing (-),
of breathing(-),
retraction ICS (-)
retraction ICS (-) 11

Normal
 PHYSICAL EXAMINATION
3. LUNG EXAMINATION

Palpation Palpable pain(-), tumor (-), Palpable pain (-), tumor (-

Arcus costae angle < 900, ), Arcus costae angle <
enlargement of ICS (-), 900, enlargement of ICS (-),
Stem fremitus decrease (-) Stem fremitus decrease (-)

Percution Sonor (+) Sonor (+)

Vesicular (+), Whezzing (-), Vesicular (+), Whezzing (-),
Auskultation
Ronchi (-) Ronchi (-)

12

Normal
 PHYSICAL EXAMINATION
3. HEART EXAMINATION
INSPECTION Ictus cordis isn’t seen.

PALPATION Ictus cordis is palpate at ICS V 2 cm lateral linea mid clavicula sinistra
thrill (-) pulsus epigastrium (-), pulsus para-sternal (-), sternal lift (-).

PERCUSSION Upper borderline of heart : ICS II sinistra sternal line

Waist of heart
Lower right borderline of heart
Lower left borderline of heart
: ICS III sinistra parastern line
: ICS V dextra sternal line
: ICS V, 2 cm mediall from
sinistra mid clavicle line
13

Normal
 PHYSICAL EXAMINATION
3. HEART EXAMINATION

PERCUSSION Aortal valve : S1 & S2 standard, additional sound (-)

Pulmonary valve : S1 & S2 standard, additional sound (-)

Tricuspid valve : S1 & S2 standard, additional sound (-)

Mitral valve : S1 & S2 standard, additional sound (-)

14

Normal
 PHYSICAL EXAMINATION
4. ABDOMEN EXAMINATION
Inspection : symetric, sycatric (-), striae (-), enlargement of
vena (-), caput medusa (-).
Auscultation : peristaltic (+) 18x/minutes
Palpation:
• Superfisial : tight (-), mass (-), epigastrial pain (-)
• Deep : abdominal pain (-), liver, kidney, and spleen
weren’t palpable, Murphy’s sign (-)
Percussion : tympani, side of deaf (-), shifting dullness
(-)
• Liver : deaf (+), right liver span 11 cm, left liver span 6 cm
• Spleen : Throbe space percussion  tympani 15

Normal
 PHYSICAL EXAMINATION
5. EXTRIMITY EXAMINATION

Extremity Superior (D/S) Inferior

(D/S)
Oedem -/- - /-
Cold Extremity -/- -/-
Physiological Reflex +/+ +/+
Icteric -/- -/-
16

Normal
ADVANCE EXAMINATION
1. HEMATOLOGICAL EXAMINATION (March 2nd, 2018)

Examination Result Normal Value

Haemoglobin 17,6 13,2 – 17,3 g/dl

Hematokrit 51,1 33 – 45 %

Leukosit 14,77 3.8 – 10,6 ribu/uL

Trombosit 366 150 – 440 ribu/uL

17

Polisitemia,
Leukositosis
ADVANCE EXAMINATION
1. HEMATOLOGICAL EXAMINATION
Hematology RESULT RESULT NORMAL VALUE
(2/3/2018) (6/3/2018)
KIMIA
Ureum 20 - 10 – 50 mg/dl
Creatinin Darah 1,02 - 0.6 – 1,3 mg/dl
Random Blood Sugar 105 - 75-110 mg/dl
Cholesterol 221 144 < 200 mg/dl
Trigliserid 305 93 <160 mg/dl
HDL - 46 30 – 64 mg/dl
LDL - 96 60 – 130 mg/dl
Uric Acid - 3,7 3,5 – 7,2 mg/dl
Natrium 136,8 135-147 mmol/l
Kalium 4,08 3,5 – 5 mmol/l
18
Chloride 109,6 95-105 mmol

Dislipidemia
ADVANCE EXAMINATION
1. HEMATOLOGICAL EXAMINATION
Hematology RESULT RESULT NORMAL VALUE
2/3/2018 5/3/2018

KIMIA

CKMB 17 - <24 U/l

High sensitive troponin I 3,9 < 19 ng/L, tidak ada nyeri dada
(TNHS)  Rule out
(Sultan Agung’s >100 ng/L  Rule in
Laboratory) 19-100 ng/L (cek Hs troponin 3
jam kemudian, jika t3-t0 >= n/L
 Rule in
High sensitive troponin I
(TNHS) - 50079,8 <2 ng/L
(CITO’s Laboratory)

19
ADVANCE EXAMINATION
1. HEMATOLOGICAL EXAMINATION

Hematology RESULT RESULT RESULT RESULT NORMAL VALUE

3/3/2018 3/3/2018 4/3/2018 4/3/2018
(0:23) (11:40) (0:31) (13:34)
APTT 23,1 23,4 22,7 22,4 21,8 – 28,0 Second

PPT 9,2 9,4 9,3 9,1 9,3 – 11,4 Second

Hematology RESULT RESULT RESULT RESULT NORMAL VALUE

5/3/2018 5/3/2018 6/3/2018 6/3/2018
(0:32) (15:06) (0:09) (06:04)
APTT 23,2 23,1 23,3 22,4 21,8 – 28,0 Second

PPT 9,0 9,1 9,3 9,1 9,3 – 11,4 Second

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ADVANCE EXAMINATION
2. ELECTROCARDIOGRAPHY EXAMINATION (2/3/2018)

21
ADVANCE EXAMINATION
2. ELECTROCARDIOGRAPHY EXAMINATION (2/3/2018)
◈ Rhytm : Sinus
◈ Regularitas : Reguler
◈ Frekuensi : 79 x/menit
◈ Axis : lead 1 = +, AvF = +  NAD
◈ Zona Transisi : V4
◈ Gelombang P : Normal
◈ Interval PR : 0,12 detik
◈ Komplek QRS : 0, 08 detik
◈ Gelombang Q : Normal
◈ Segmen ST : Normal
◈ Gelombang T : T tall di V1, V2
22

Hiperacute T wave
ADVANCE EXAMINATION
2. ELECTROCARDIOGRAPHY EXAMINATION (3/3/2018)

23
ADVANCE EXAMINATION
2. ELECTROCARDIOGRAPHY EXAMINATION (3/3/2018)
◈ Rhytm : Sinus
◈ Regularitas : Reguler
◈ Frekuensi : 88 x/menit
◈ Axis : lead 1 = -, AvF = -  RAD Extrem
◈ Zona Transisi :-
◈ Gelombang P : Normal
◈ Interval PR : 0,12 detik
◈ Komplek QRS : 0, 08 detik
◈ Gelombang Q : Q patologis di V2, V3, V4, V5, V6
◈ Segmen ST : ST Elevasi di V2, V3, V4, V5
◈ Gelombang T : Normal
24

STEMI ANTERIOR
ADVANCE EXAMINATION
2. ELECTROCARDIOGRAPHY EXAMINATION (4/3/2018)

25
ADVANCE EXAMINATION
2. ELECTROCARDIOGRAPHY EXAMINATION (4/3/2018)
◈ Rhytm : Sinus
◈ Regularitas : Reguler
◈ Frekuensi : 79 x/menit
◈ Axis : lead 1 = -, AvF = +  RAD
◈ Zona Transisi :-
◈ Gelombang P : Normal
◈ Interval PR : 0,12 detik
◈ Komplek QRS : 0, 16 detik, R bertakik di LII, V4, V5, V6
◈ Gelombang Q : Normal
◈ Segmen ST : Normal
◈ Gelombang T : T inversi di LII, V1, V2, V3, V4, V5, V6
26

LBBB
ISKEMIK ANTERIOT EKSTENSIF
ADVANCE EXAMINATION
2. ELECTROCARDIOGRAPHY EXAMINATION (5/3/2018)

27
ADVANCE EXAMINATION
2. ELECTROCARDIOGRAPHY EXAMINATION (5/3/2018)
◈ Rhytm : Sinus
◈ Regularitas : Reguler
◈ Frekuensi : 83 x/menit
◈ Axis : lead 1 = -, AvF = +  RAD
◈ Zona Transisi :-
◈ Gelombang P : Normal
◈ Interval PR : 0,12 detik
◈ Komplek QRS : 0, 08 detik
◈ Gelombang Q : Q patologis di V2, V3, V4, V5, V6
◈ Segmen ST : ST Elevasi di V2, V3, V4
◈ Gelombang T : T Inversi di V3, V4, V5, V6
28

STEMI ANTERIOR
ADVANCE EXAMINATION
2. ELECTROCARDIOGRAPHY EXAMINATION (6/3/2018)

29
ADVANCE EXAMINATION
2. ELECTROCARDIOGRAPHY EXAMINATION (6/3/2018)
◈ Rhytm : Sinus
◈ Regularitas : Reguler
◈ Frekuensi : 75 x/menit
◈ Axis : lead 1 = -, AvF = -  RAD Extrem
◈ Zona Transisi :-
◈ Gelombang P : Normal
◈ Interval PR : 0,12 detik
◈ Komplek QRS : 0, 08 detik
◈ Gelombang Q : Q patologis di V2, V3, V4, V5, V6
◈ Segmen ST : ST Elevasi di V2, V3, V4, V5, V6
◈ Gelombang T : Normal
30

STEMI ANTERIOR
ADVANCE EXAMINATION
3. X- RAY THORAX (2/3/2018)

31
ADVANCE EXAMINATION
3. X- RAY THORAX (2/3/2018)

INTERPRETATION :
 Cor : Bentuk dan Letak normal
 Pulmo : Corakan vaskular tak meningkat, tak tampak gambaran
infiltrat
 Diagfragma dan sinus kostofrenikus tak tampak kelainan

KESAN :
 COR TAK MEMBESAR
 PULMO TAK TAMPAK GAMBARAN INFILTRAT
32
ABNORMALITAS DATA
 HISTORY TAKING  Laboratory Examination
1. Chest Pain 10. Polisitemia
2. Chest discomfort 11. Leukositosis
3. Dispnea 12. Dislipidemia
4. Palpitate 13. Increase of Troponin
5. Sweating  ELECTROCARDIOGRAM
6. Bloated 14. ST Elevasi
7. HT History 15. T Tall
 HISTORY TAKING 16. T inversi
8. BP 151/108 17. Q patologis
33
9. BMI 26,4 18. R bertakik
 STEMI HIPERTENSION DISLIPIDEMIA
1, 2, 3, 4, 5, 6, 12 GRADE I
12
13, 14, 15, 16, 17, 7, 8
18

POLISITEMIA LEUKOSITOSIS OVERWEIGHT

10 11 9

34
 STEMI
Assesment
• etiology; CAD
IP. Dx
• Angiography
IP. Tx
• Non-pharmacology
• O2
• Restriction physical activity
IP. Tx
• Pharmacology

• Anticoagulant :
• Enoxparin 30 mg i.v. Bolus followed 15 min later by 1mg/kg
subcutan every 12 hours until revascularization or hospital
discharge for a maximum of 8 days.
• Anti platelet :
• Clopidogrel 300 mg (loading dose) and 1 x 75 mg
(maintenance)
• Aspilet oral 1x 160mg (loading dose) and 1 x 80 mg
(maintenance)

• ANTI-ISKEMIK
• Beta blocker
• Bisoprolol
• Nitrat Sublingual 5mg (prn)
IP. Mx

• Vital sign , EKG, APTT, PPT

IP. Ex

• Bed rest
• Reducing emotional stress
• Stop smoking and drink coffee
 Hypertension Grade I
• Ass : Risk factor of cardiovaskular
• IP Dx : Asam urat, Circumference, ABPI, GFR
• IP Tx :
 Non Pharmacology
 Low Salt intake
 Reduce activity
• Pharmacology : Captopril 12.5 mg 2x1
•
IP Mx: Vital Sign

IP Ex:
 Stop smoking
 Diet kolesterol

 Diet low salt

 Routine consumption drugs

 DISLIPIDEMIA
◈ Ass : High intake of cholestrol
◈ IP Dx : ASCVD score risk
◈ IP Tx :
Pharmacology :
Atorvastatin 1 x 40 mg PO
Non pharmacology
◈ Lyfe style management
◈ Explain to patients about
the condition, and
complication that may
occur
◈ Exercise 60 minutes with
aerobic and resistance
training
◈ Achieve ideal body mass
index and body weight
• Ip.Mx : Cholesterol total, HDL, LDL, Trigliserid

• Ip.Ex :

• Low diet of cholestrol

• Eat high fiber diet and low fat
• Reduce fatty food, soda and junk food
• Low exercise regularly
 OVERWEIGHT

◈ ASS : - IP Mx: - Monitoring weight

◈ IP Dx : - - Waist circumference

IP Tx: Non Pharmacology

- Daily Calori ◈ IP Ex: - Education of obesity

- Physical Exercise - Diet low calori

- Change of dietary - Diet low fat

habit
 POLISITEMIA

◈ ASS : Etiologi IP Mx: - Hematology examination

◈ IP Dx : -

IP Tx: Flebotomi ◈ IP Ex: - Education of the disease

and theraphy of the disease
THANKS!
❤
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