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CASE REPORT

Sunday, 24 February 2019

AMIRAH SAKINAH ALI


N I ’ M AT U L M U N A W W A R A H
A N G E L I N E TA N D I A W A N
VICTORIO TUNGADI
Patient Identity
Name : Ny. S
Date of birth : 17-4-1955 (63 years old)
MR : 874836
Date of Admission : February 24th 2019
DPJP : PT
History Taking
Chief complaint : Chest pain
Present illness history :

A 63 y.o woman came to the Emergency Room with chief complaint of chest pain, which
was felt since 8 hours ago. Chest pain was intermittten, pressed-like sensation, duration 10
minutes, relieved by medication (isosorbid dinitrat 5 mg sublingual). There were
diaphoresis, nausea and vomiting. There was history of shortness of breath aggravated by
activity which was felt since 2 days ago, PND (-), DOE (+), Ortopnoe (+). There was history
of diabetes and hypertension.
History Taking
Risk factor :
Modifiable : Hypertension, Diabetes Mellitus
Non Modifiable : Age

Past illness history :


Hypertension was present almost 5 years, uncontrolled
Diabetes Mellitus was present almost 3 years , uncontrolled
Physical Examination
BP : 120/70 mmHg, HR : 70 bpm regular, RR : 24 tpm, Temp : 36,5C.
Conjunctiva not anemic, sclera not icteric.
JVP R+2 cmH2O
Vesicular breathing sound, Ronchi rales at mediobasal bilateral, no wheezing.
S1/S2 regular, no audible murmur
Normal Peristaltic, hepar and lien unpalpable
Extremity : warm , no edema
ECG (24/2/2019)

Sinus rhythm, HR 65 bpm, axis +30 degree, P wave 0,08 s, PR interval 0.20s, QRS 0,08s, T
inverted V1-V3
Conclusion : Sinus Rhythm, HR 65 bpm, Normoaxis, ischemia anteroseptal
Electrocardiography (25/2/2019)
Test Type Result Normal Value

Laboratory Findings
WBC
HGB
13,3
12,7
uL
uL
4-10x103
12-16
HCT 37 % 37-48
PLT 291 uL 150-400x103
GDS 95 mg/dl 140
Ureum 40 mg/dl 10-50
Creatinine 0,81 mg/dl F (<0,01)
SGOT 112 U/L <38
SGPT 66 U/L <41
PT 10,1 S 10-14
aPTT 24,1 S 22-30
INR 0,97 - -
Na 134 Mmol/l 136-145
K 4 Mmol/l 3,5-5,1
Cl 99 Mmol/l 97-111
HS Troponin I 12,7 Ng/l 8-29
Thorax AP (24/2/2019)
Chest X-Ray PA
Normal bronchovascular marking
- Cor enlargement : CTI 0.58, downward apex, dilatation and
elongation aortae
-Normal both sinuses and diaphragm
-Intact Bones
- Normal Soft Tissue
Conclusion:
Cardiomegaly with dilataio, elongation et atherosclerosis
aortae
Echocardiography (24/2/2019)
• Normal LV systolic function, EF 62,5% (TEICH), EF 60,1%
(BIPLANE) Conclusion :
• Cardiac chamber dimension within normal limit • Normal LV and RV Systolic
• LVEDd 4.08 cm, LVEDs 2,72 cm LA Mayor 5,2 cm, LA Minor
3,7 cm, RA Mayor 4,1 cm, RA Minor 1,7 cm, RVDB 2,1 cm
Function, EF 57,3%
• Left Ventricular Hypertrophy: positive concentric (LVMI 137 (BIPLANE)
g/m2, RWT 0,65) • Concentric LVH
• Myocardial movement: global normokinetic
• Enough RV systolic function, TAPSE 1,8 cm
• Mild Aorta Regurgitation
• Valves : • Mild diastolic dysfunction
o Mitral : normal function and movement
o Aorta : 3 cuspis: Calcification (-), AR mild (Arvht 564 ms)
o Tricuspid : normal function and movement
o Pulmonal : normal function and movement
o E/A <1
Assessment
Unstable Angina Pectoris
Congestive Heart Failure NYHA III
Coronary Artery Disease
Controlled Hypertension
Controlled Diabetes Mellitus Type 2
Mild hyponatremia
Dyspepsia
Management
IVFD NaCl 0,9% 500 cc/24h/IV
Antiaggregation platelet : Aspilet 80 mg/24h/oral,Clopidogrel 75 mg/24h/oral
Antikoagulan : Arixtra 2,5mg/24h/SC
Diuretic : Furosemid 40mg/12h/IV, Spironolactone 25mg/24h/oral
ACE-Inhibitor : Captopril 12,5 mg/8h/oral, Ramipril 25mg/24h/oral
PPI : Lansoprazole 30 mg/24h/IV
Anti-emetic : Domperidone 10 mg/8h/oral
Statin : Atorvastatin 40mg/24h/oral
Plan
Transferred to CVCU

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