Morning Report

Saturday, March 7th 2020

Maya
Andrea
Nur Arwita
Zulkarnaen
Fathlina
Bambang
Godeberta
Hadi
Zulkifli
 RESUME
No Name Diagnosis
1 Mr Paserei/56 yo NSTEMI, CHF, Post cardiogenic shock, CAP, AS moderate
2 Mr M Ilham/42yo Massive Pericardial Efussion with sign of Cardiac Tamponade post
pericardiocentesis, Paroxysmal AF, CAP, Bilateral pleural effusion
3 Mr Husain/ 57yo STEMI extensive anterior onset 9 hours KILLIP II, VT with stable
haemodynamic, Stress Hyperglycemia dd/ DM type 2, Hyponatremia,
Hyperkalemi
4 Mr Umar/60yo STEMI Whole Anterior wall onset 5 hours KILLIP I post thrombolytic,
HHD, DM type 2
5 Mr Amril/63 yo STEMI inferior + RV onset 9 hours KILLIP II, TAVB, AKI dd/ acute on
CKD, HHD, Elevated liver enzyme
6 Mr Dg Rapi/50 yo AFRVR, RHF, Severe MR, Severe TR, TB paru on treatment intensive
phase, Trombositopenia
7 Mr Edy/50 yo UAP
8 Mr Syamsul/66 yo UAP, Hypokalemia, Epilepsy
9 Mr Agung/43 yo Recent STEMI extensive anterior KILLIP 1, CAP
 1st Patient
Name : Mr. P
Age : 56 years old
Address : Makassar
MR : 913420
Date of Admission : March 7th, 2020
DPJP : dr AFG

The patient was referred from Faisal Hospital with diagnosis NSTE ACS,
post Cardiogenic shock, ADHF, CAP, AKI dd Acute on CKD
 History Taking
A 56 y.o man was admitted to PJT with Chest discomfort.

It was felt since 3 days before admission induced by activity, pressed like sensation, radiated
to the back, not relieved with rest, accompanied with diaphoresis and nausea, but no
vomiting. There was history of chest discomfort, intermittently, since 2 years ago. There was
shortness of breath , DOE (+) PND (+) Orthopnea (+). Cough (+) for 3 days, Fever (+). There
was history of chest pain and SoB 2 years ago, patient suggested to coronary angiography but
refused.

Coronary Risk Factor:

• History of hypertension (-)
• History of DM (-)
• History of smoking (+) for 20 years, 1 pack/day
He was treated at Faisal Hospital and get aspilet, clopidogrel, heparin, simvastatin,
dobutamin, ceftriaxone, paracetamol, N-Ace and Furosemide.
 Physical Examination
• BP: 113/66 mmHg, HR : 99 bpm regular, RR :
28 tpm, T: 36.40C
• Conjunctiva not anemic, sclera not icteric
• JVP R+3 cmH2O (position 30◦)
• Vesicular breath sound, ronchi (+) at basal
bilateral, wheezing (-)
• Regular heart sound, murmur (+) systolic grade
2/6 at ULSB
• Abdomen : peristaltic normal
• Extremity: warm, No oedema
ECG (7/3/2020) at Faisal Hospital
5.27
ECG (7/3/2020) at PJT ER
16.11
 Lab. Findings (18/09/2019)
WBC 9.0 4-10 x 103/mm3 103/mm3
N/L/M/E/B 81.5/14.4/3.2/0.3/0.6
HGB 14.1 g/dl 12-16
PLT 229 150-400 x 103/mm3
HCT 40 37-48 %
SGOT 107 <38 U/L
SGPT 42 <41 U/L
Ureum 22 10-50 mg/dl
Creatinin 0.60 <1.3 mg/dl
eGFR 112.4 mL/min/1.73m2
RBG 76 <140 gr/dl
Sodium 139 136 – 145 mmol/l
Potassium 4.3 3.5 – 5.1 mmol/l
Chloride 108 97 – 111 mmol/
PT/APTT/INR 10.4/36.6/1.00 10-14/22-30 detik
hs Troponin I 22191 17-50 ng/l
Chest Xray (5/03/2020)
Faisal Hospital
• Infiltrate at medial both of
lung
• Cor enlarged with CTI 0,72
with grounded apex
• Normal aorta
• Bone intact
• Soft tissue normal

Conclusion :
• Cardiomegaly
• Pneumonia
 Echocardiography (7/3/2020)
• Heart valves:
• Mitral: MR mild (MR ERO 0.03 cm2, MR vol 3 ml)
• Aorta: 3 cuspis, calcification positive RCC, NCC, LCC, AS moderate (AVA planimetry 1.19 cm2), AV mean PG (AV VTI 34.5 cm, AVVmax 2 m/s)
• AS moderate, AVvmax 3,65 m/s, AV mean PG 35,9 mmhg, AVA Planimetry 1,1 cm 2
• Tricuspid : TR mild ( TR Vmax 3.5 m/s, TR max PG 51 mmHg, TR VC unseen)
• Pulmonal : PR Mild (PR PHT 936 ms, jet <1/3 RVOT)
• Dimension of heart chambers :
• LA : LA major 7,0 cm, LA minor 4.4 cm, LAVI 43.4 ml/m2
• LV : LVEDd 6.1 cm, LVEDs 5.28 cm, SEC +
• RA : RA major 5.4 cm, RA minor 3.9 cm, RA area 19.5 cm2
• RV : RVDB 3.4 cm
• Aorta : Ao 2.8 cm, LA 4.5 cm, LA/Ao 1.61
• Decreased left ventricular systolic function, Ejection Fraction 28.3 % (TEICH), 25.5 % (Biplane)
• Normal right ventricular systolic function, TAPSE 1,8 cm lat Svel 10,6 cm/s
• Left Ventricular Hypertrophy : eccentric positive (LVMI 177 g/m2, RWT 0,32)
• Myocardial Movement : Akinetic basal mid, anteroseptal, inferoseptal, akinetic apicoseptal, apicoanterior, hypokinetic others.
• eRAP : 15 mmHg (IVC expiration 12.3 cm, inspiration 1.19 cm)
• E/A > 2 , E’ Med : 2.5 m/s, E’Lat : 2.1 m/s E/E’ 52,95 cm/s
• LVSV: 38 ml , LVCO 3.0 l/min LVOT VTI 9.35 cm
Conclusion :
Decreased LV systolic function, EF 25.5% (BIPLANE)
Normal RV systolic function, TAPSE 1.8 cm
Dilatation all chambers
Eccentric LVH
Mild MR, Mild TR, Mild PR, moderate AS
Grade III diastolic dysfunction
 Working Diagnosis
• Non ST elevasi Miokard infark high risk
(GRACE score 107 points, 5% probability of death from
admission to 6 months. TIMI score 3 points, 13% risk at 14 days
of: all-cause mortality, new or recurrent MI, or severe
recurrent ischemia requiring urgent revascularization)
• CHF NYHA III
• Post cardiogenic shock
• CAP CURB 65 score 0
• AS moderate
 Management
• Natrium Chloride 0.9% 500 cc/24 hours/intravenous
• Aspilet 80mg/24 hours/oral
• Clopidogrel 75mg/24hours/oral
• Heparin 700iu/hours/sp
• ISDN 10 mg/8 hours/oral
• Atorvastatin 40mg/24hours/oral
• Furosemide 40mg/12hours/iv
• Ceftriaxone 2 g/24 hours/iv
• N Ace 200mg/ 8 hours/oral
• Paracetamol 500mg/8 hours/oral
 Plan:

• Early invasive strategy

• Check Profil Lipid
• Transfer to CVCU
• Consult to pulmonology
 2nd Patient Identity
Name : Mr. MI
Age : 42 years old
Address : Makassar
MR : 913424
Date of Admission : 7th March 2020
DPJP : dr. AFG

Patient was referred from Hermina Hospital with diagnosed Cardiac Tamponade , Bilateral
Pleural Effusion, Pulmonary Oedema
 History Taking
Chief complain with Shortness of breath

It was felt since 3 weeks ago, worsened since 3 days before admission, aggravated
by activity. DOE (+), PND (+) Orthopneu (+), Chest pain (-), Palpitation (+), nausea (-),
vomitting (-), cought (+) since 2 months ago, white sputum, no blood, no Fever,
lower leg odema since 1 month ago. There was no history chest pain or SoB.

Coronary Risk Factor :

History of hypertension (-)

History of diabetes mellitus (-)

No family history with cardiac disease

History of smoking 20 years , 2 pack / day

History medication at Hermina hospital: ceftriaxon, omeprazole, furosemid,

spironolakton, digoxin
 Physical Examination
• BP: 54/33 mmHg, HR : 130 bpm, RR : 30 tpm,
T: 36,7 0C
• Conjunctiva not anemic, sclera not icteric
• JVP R+4 cmH2O
• Vesicular breath sound, diminished at basal
bilateral , rales (-), wheezing (-)
• S1/S2 regular heart sound, muffled heart
sound, murmur (-)
• Extremity: warm, oedema pretibial (+)
ECG (7/3/2020) Hermina hospital
 ECG at PJT
7th March 2020 (18.47)
Chest X-Ray Hermina Hospital
5-3-2020
Interpretation

• Dilatation Suprahilar both of lung

• Cor look like very enlarged
• Heart border, Sinus and diaphragma
covered
• Normal aortae
• Bone intact
• Soft tissue normal

-Conclution :
•Cardiomegaly with sign of pulmonary
oedema
•Bilateral pleural effusion
 Lab. Findings (7/3/2020)
WBC 16.0 103/mm3 4-10 x 103/mm3
N/L/M/E/B 91.0/2.3/6.3/0.1/0.3 %
HGB 15.2 g/dl 14-18
HCT 45 % 37.0-48.0
PLT 151 103/mm3 150-400 x 103/mm3
SGOT 32 U/L < 38
SGPT 73 U/L < 41
Ureum 117 mg/dl 10-50
Creatinin 1.02 eGFR 90.2 mg/dl <1,3
PT 13.1 s 10 – 14
aPTT 19.8 s 22.0 – 30.0
INR 1.28 -
Sodium 133 mmol/l 136 – 145
Potassium 3,9 mmol/l 3.5 – 5.1
chloride 96 mmol/l 97 – 111
RBG 90 Mg/dl 140
 Working Diagnosis
• Massive Pericardial Efussion with sign of Cardiac
Tamponade
• Paroxysmal AF
• Community acquired pneumonia CURB 65 score 2
• Bilateral pleural effusion
 Management
• Pericardiocentesis
• Ceftriaxon 2 g/24 hours/iv
• N Ace 200mg/8 hours/oral
 Plan

• Pericard fluid analysis and culture

• Aspirasion pericard fluid / 12 hours
• Transfer to CVCU
• Consult to pulmonology
Chest Xray (7/3/2020)

• Haziness at parahilar and

paracardial both of lungs
• Cor can not be evaluated, look like
a cardiomegaly
• Heart border, Sinus and
diaphragma covered with
periapical capping.
• Bone intact
• Soft tissue normal

Conclusion :
• Cardiomegaly with sign of lung
oedema
• Bilateral pleural effusion
 Echocardiography (7/3/2020) post pericardiocentesis
• Heart valves:
• Mitral: Normal function and movement
• Aorta: 3 cuspis, calcification negative, Normal function and movement
• Tricuspid : TR mild ( TR Vmax 2,3 cm/s TR max PG 22 mmhg TRVC under)
• Pulmonal : Normal function and movement PVacct 92 ms
• Dimension of heart chambers :
• LA : LA major 5.0 cm, LA minor 3,1 cm, LAVI 15.0 ml/m2
• LV : LVEDd 3,1 cm, LVEDs 1.9 cm
• RA : RA major 4.5 cm, RA minor 4.1 cm
• RV : RVDB 2.5 cm
• Aorta : Ao 2.6 cm, LA 3.3 cm, LA/Ao 1.27
• Normal left ventricular systolic function, Ejection Fraction 68.4 % (TEICH), 60.5 % (Biplane)
• Normal right ventricular systolic function, TAPSE 1.0 cm S’ lateral 6.48 cm/s
• Left Ventricular Hypertrophy : negative (LVMI 50.3 g/m2, RWT 0,72)
• Myocardial Movement : global normokinetic
• eRAP : 815mmHg (IVC expiration 2.4 cm, inspiration 1.8 cm)
• E/A Fusion on AF
• LVSV 30 ml LVCO 3.5 l/m LVOT VTI 14.9 cm
• Pericardial effusion right posterior 1.22 cm, leftlateral 2.41 cm, anterior 2.38, right lateral 2.39
• view plax posterior 2.64 cm, view subcostal left lateral 1.85 cm, right lateral 0.6 cm
• Trikuspid inflow 15% Mitral inflow 15%, RA coelaphibility index 19%

Conclusion :
Normal LV systolic function , EF 60.5% (BIPLANE)
Decreased RV systolic Function
Mild TR
Large pericardial effusion
 Pulmonology division
• Assessment :
– Bilateral pleural efussion
– CAP CURB 65 score 0
– Pericardial efussion
– Candidiasis oral
• Planning:
– Ceftriaxon 2 g/ 24 hours/iv
– N-Ace 200mg/ 8 hours/ oral
– Thoracosintesis  Fluid analysis
– Sputum BTA, gram and fungi
– Check HIV, Anti HCV and HBs Ag
 3rd Patient
Name : MH
Age : 57 years old
Address : Gowa
MR : 913431
Date of Admission : March 7th, 2020
DPJP : dr. AFG

The patient was referred from

Syekh Yusuf Hospital, Gowa with diagnosed STEMI
 History Taking
A 57 y.o man was admitted to PJT with Chest pain.

It was felt since 9 hours before admission, triggered with activity. The pain radiates to the back,

duration >20 minutes, accompanied with diaphoresis, not relieved with rest, VAS 9/10. There was

shortness of breathing, no DOE, PND nor orthopnea. There is no history of chest pain nor shortness

of breathing.

There was no history of HT nor DM

There was no family history of cardiac disease

History of smoking since >30 years ago, 2 packs/day

History of medication at Gowa hospital: Aspilet 80mg, CPG 75mg, ISDN 5mg/SL, Ranitidin 50mg/iv,

Ondansetron 4mg/iv
 Physical Examination
• BP: 103/74 mmHg, HR : 124 bpm, RR : 24
tpm, T: 36.70C, O2 saturation 99% with nasal
kanul 5 lpm
• Conjunctiva not anemic, sclera not icteric
• JVP R+2 cmH2O (position 30◦)
• Vesicular breath sound, rales (+) base of
both lungs, wheezing (-)
• Regular heart sound, murmur (-)
• Abdomen : peristaltic normal
• Extremity: warm, oedema (-)
 ECG (7/3/2020) at
Syech Yusuf Hospital (onset 8 hour)
ECG (7/3/2020) at Cardiac Centre
(onset 9 hours)
 ECG (7/3/2020) at Cardiac Centre
onset 9 hour post bolus amiodaron 300 mg
 Lab. Findings (7/3/2020)
WBC 20,4 4-10 x 103/mm3 103/mm3
N/L/M/E/B 85,2/10,3/4,1/0,0/0,4
HGB 14,8 g/dl 12-16
PLT 343 150-400 x 103/mm3
SGOT 57 <38 U/L
SGPT 41 <41 U/L
Ureum 35 10-50 mg/dl
Creatinin 1,35 eGFR 57.9 <1.3 mg/dl
RBG 286 <140 gr/dl
Sodium 133 136 – 145 mmol/l
Potassium 5,7 3.5 – 5.1 mmol/l
Chloride 98 97 – 111 mmol/
PT/APTT/INR 9,8/24,2/0,94 10-14/22-30 detik
HS Troponin I 4890,6 M (<17-50) ng/L
 Working Diagnosis
• STEMI extensive anterior onset 9 hours KILLIP II
(TIMI score 7, 23% risk of All-cause mortality at 30
days. GRACE score 141 points, 16% probability of
death from admission tp 6 months)
• VT with stable haemodynamic
• Stress Hyperglycemia dd/ DM type 2
• Hyponatremia
• Hyperkalemi
 Management
• NaCl 0,9% 500cc/24hours/intravenous
• Amiodarone 300mg/bolus/intravenous,
Amiodarone 360mg/intravenous in 6 hours
Amiodarone 540mg/intravenous in 18 hours
• Alteplase 15mg/bolus/intravenous
Alteplase 50mg/intravenous in 30 minutes
Alteplase 35mg/intravenous in 60 minutes
• Aspilet 160mg/oral
• Clopidogrel 300mg/oral
• Cedocard 2mg/hour/syringepump
Time Physical Examination Management
21.45 S: decreased of stop thrombolytic, cito consult to
consciousness 15 minutes neurology
after having thrombolytic
agent
O: pupils anisokor, BP
98/60, HR 120 bpm
A: Susp. haemoragic
stroke
22.00 S: no response Cardiopulmonary resuscitation 15
O : Monitor PEA, no pulse minutes + Epinefrin/intravenous
A : Cardiac arrest Code blue
22.15 S: no response Bolus SA 2 amp
O : Monitor SR, HR 30 Dobutamin 5mcg/min/kg/sp
bpm, BP 60/40 Vascon 0.05 mcg/min/kg/sp
A : ROSC
Patient ROSC several times

23.15 The patient was decleared Death

 4th Patient Identity

Name : Mr. US
Age : 60 y.o
Address : Makassar
MR : 913437
Date of Admission : March 7th, 2020
DPJP : dr. Az Hafid

Patient was referred from Grestelina Hospital with diagnosis ACS

 History Taking
• Chief complaint : Chest pain
• Patient admitted to the PJT with chief complaint chest pain since 5 hours ago
triggered with emotional, Pressed and stabbing like sensation, not relieved with
nitrat SL, radiating to back and neck, with > 20 minutes duration and diaphoresis.
NRS Score was 6/10 when he came to PJT ER. History of Chest Pain (-). Shortness
of breath (+), History of SOB (-). Palpitation(-), nausea (+), vomiting (-)
• History of hypertension(+) 5 years , take medicine regularly

• History of diabetes mellitus (+) 5 years, without medicine

• History of smoking (+) > 20 pcs/days for > 10 years

• The patient was given aspilet 160 mg, clopidogrel 300 mg, ISDN 5 mg sublingual.
 Physical Examination
• BP: 160/90 mmHg, HR : 80 bpm regular, RR : 20 tpm, T: 36.50C
SpO2 : 99%
• Conjunctiva not anemic, sclera not icteric
• JVP R+2 cmH2O (position 30◦)
• Vesicular breath sound, no rales nor wheezing
• S1S2 regular, gallop(-) no audible murmur
• Hepar/lien not palpable, Peristaltic (+) normal
• Extremity: no edema
ECG from Grestelina Hospital
7th March 2020
(onset 2.5 hours)
 ECG at PJT
7th March 2020 (onset 5 hours)
 ASSESSMENT
• STEMI Whole Anterior wall onset 5 hours
KILLIP I (TIMI score 3, 4.4 % risk of All-cause mortality at 30
days. GRACE score 99 points, 4% probability of death from
admission tp 6 months)
• Hypertensive heart disease
• DM type 2
 Management
• Trombolitic With Actylise :
– 15 mg bolus intravenous
– 50 mg/intravena over 30 minutes
– 35 mg/intravena over 60 minutes
Ecg post Thrombolytic
 Lab. Findings (7/3/2020)

WBC 12.9 103/mm3 4-10 x 103/mm3

Neut/Lymph/Mono/Eo/Baso 83.8/11.1/4.6/0,2/0,3 %

HGB 14.9 g/dl 12-16

PLT 248 103/mm3 150-400 x 103/mm3
PT 10,0 Second 10-14
INR 0.96
APTT 24.4 second 22,0-30,0
SGOT 376 U/L < 38
SGPT 56 U/L < 41
Ureum 125 mg/dl 10-50
Creatinin 0.99 e GFR 92.5 mg/dl <1,1
RBG 226 gr/dl <140
Natrium 139 mmol/l 136 – 145
Kalium 4.5 mmol/l 3.5 – 5.1
Klorida 102 mmol/l 97 - 111
Hs Troponin I 779.1 ng/l Laki-laki :17-50
Chest X-Ray PJT
8-3-2020
Interpretation

• Dilatation Suprahilar both of lung

• Cor enlarged with CTI 0,52 concave
cardiac waist with grounded apex
• Dilatatio aortae
• Bone intact
• Soft tissue normal

-Conclution :
•Cardiomegaly with sign of pulmonary
congestion
•Dilatation aortae
 Echocardiography
(7/3/2020)
Heart valves:
• Mitral: MR mild (MR ERO 0,06 cm2, MR Vol 9 ml)
• Aorta: 3 cuspis, calcification negative, normal movement and function
• Tricuspid : normal movement and function
• Pulmonal : normal movement and function (PV Acct 130 ms)
Dimension of heart chambers : Normal
• LA : LA major 4.9 cm, LA minor 3.6 cm, LAVI 24.2 ml/m2
• LV : LVEDd 5.49 cm, LVEDs 4.16 cm
• RA: RA major 4.5 cm, RA minor 3.1 cm
• RV: RVDB 2.3 cm
• Aorta : Ao 3.2 cm, LA 3.5 cm, LA/Ao 1.06
• Decreased left ventricular systolic function, Ejection Fraction 47.8 % (TEICH), 43.7 % (Biplane)
• Normal right ventricular systolic function, TAPSE 2.0 cm, S’ lateral velocity 14.7 cm/s
• Left Ventricular Hypertrophy : concentric positive (LVMI 154 g/m2, RWT 0.54)
• Myocardial Movement : Akinetic basal mid, anteroseptal, apicoanterior, hypokim=netic basal mid, anterolateral apicoseptal.
• eRAP : 15 mmHg (IVC expiration 1.8 cm, inspiration 1.5 cm)
• E/A < 1 E’ medial velocity 5.61 cm/s E’ lateral velocity 7.35 cm
Conclusion :
• decreased LV systolic function, EF 43.7% (BIPLANE)
• normal RV systolic function, TAPSE 2.0 cm
• LA and LV Dilatation
• MR Mild
Concentric LVH
• Segmental akinetic and hypokinetic
• 1 st grade left ventricular diastolic dysfunction
 Management
• NaCl 0.9% 500cc/24hours/drips
• Aspilet 80mg/24 hours/oral
• Clopidogrel 75 mg/24 hours/oral
• Atorvastatin 40mg/24 hours/oral
• Fondaparinux 2,5 mg/24 hours/subcutan
• ISDN 2mg/hours/ sp
• Ramipril 2.5mg/24hours/ oral
 Plan
• Routine early PCI strategy
• Profil lipid
• Consult to EMD
• Transfer to CVCU
 EMD division
• Assessment :
– DM type 2 non obese
– STEMI whole anterior
– HT grade II
• Planning:
– Diet DM 1700 kkal
– Levemir 10 unit / subcutan
– Novorapid 6-6-6 unit / subcutan
– Premeal RBG Monitoring
 5th Patient
Name : AH
Age : 63 years old
Address : Makassar
MR : 209538
Date of Admission : March 8th, 2020
DPJP : dr. AFG

The patient was referred from RSUD Pemkot Makassar,

diagnosed with inferior STEMI
 History Taking
A 63 y.o man was reffered to cardiac centre with Chest pain.

It was felt since 6 hours before admission with NRS 9/10, when arrived at cardiac centre
the NRS was 5/10. triggered with activity, The pain radiated to the back, duration >10
minutes, accompanied with diaphoresis. There was shortness of breathing, no paroxysmal
nocturnal dyspnea, no dyspnea on effort, no orthopnea. History of being admitted
because of the shortness of breathing and chest pain for 2 weeks at RSUD Pemkot
Makassar but patient not routine control.

Major Coronary Risk Factor:

• History of hypertension (+) since 5 years ago and taking amlodipin 5 mg
• History of DM (-)
• History of smoking (+), stopped 15 years ago

History of medication at RSUD Makassar: ISDN 5 mg SL, ranitidin iv, CPG 150mg, aspilet
160 mg
 Physical Examination
• BP: 92/60 mmHg, HR : 90 bpm, RR : 24
tpm, T: 36.50C, O2 saturation 99% room air
• Conjunctiva not anemic, sclera not icteric
• JVP R+2 cmH2O (position 30◦)
• Vesicular breath sound, rales (+) base of
both lungs, wheezing (-)
• Regular heart sound, murmur (-)
• Abdomen : normal peristaltic
• Extremity: warm, oedema (-)
ECG (7/3/2020) at RSUD Makassar
(onset 4.5 hours)
ECG (8/3/2020) at Cardiac Centre
onset 6 hours
ECG (8/3/2020) at Cardiac Centre
onset 6 hours
 02.15 WITA
• S: seizure
• O: ecg monitor VT, no pulse
• A: VT pulseless
• P: CPR 1 cycles  ROSC

• S: chest pain (+), VAS 9/10

• O: GCS 15, HR 30 bpm, weak pulse, BP not measurement, SpO2
99%
• P:
- ECG 12 lead
- SA 2 ampules/intravenous
ECG (8/3/2020) at Cardiac Centre
(onset 9 hours)
 Lab. Findings (8/3/2020)
WBC 8,8 4-10 x 103/mm3 103/mm3
N/L/M/E/B 87,2/6,6/3,9/0,1/0,2
HGB 14,8 g/dl 12-16
PLT 197 150-400 x 103/mm3
SGOT 280 <38 U/L
SGPT 122 <41 U/L
Ureum 58 10-50 mg/dl
Creatinin 1,85 e GFR 37.6 <1.3 mg/dl
RBG 140 <140 gr/dl
Sodium 139 136 – 145 mmol/l
Potassium 5,0 3.5 – 5.1 mmol/l
Chloride 104 97 – 111 mmol/
PT/APTT/INR 11,6/27,3/1.12 10-14/22-30 detik
HS Troponin I >40000 M (<17-50) ng/L
 Working Diagnosis
• STEMI inferior + RV onset 9 hours KILLIP II (TIMI
score 8, 27% risk of All-cause mortality at 30 days.
GRACE score 152 points, 21% probability of death
from admission tp 6 months)
• Total AV block
• Acute Kidney Injury dd/ acute on chronic kidney
disease
• Hypertension Heart Disease
• Elevated liver enzyme
 Management
• NaCl 500 cc/24hours/intravenous
• Actylise 15mg bolus/intravenous
Actylise 50mg/intravenous in 30 minutes
Actylise 35mg/intravenous in 60 minutes
• Aspilet 80 mg/ 24 hours/oral
• Loading Clopidogrel 150mg/oral
Clopidogrel 75 mg/ 24 hours/oral
• Isosorbid Dinitrate 5 mg/sublingual, if chest pain
• Dopamin 5mcg/kg/BB/minute/syringepump
Time Physical Examination Management
02.40 S: decreased of Cardiopulmonary resuscitation +
consciousness 10 minutes Epinefrin/intravenous
after having thrombolytic Code blue
agent
O: pupils isokor, no pulse
A: PEA
03.10 S: no response Dobutamin 5mcg/min/kg/sp
O : Monitor TAVB, pulse Vascon 0.05 mcg/min/kg/sp
(+), BP not measurement
A : ROSC
03.15 S: no response Cardiopulmonary resuscitation +
O : Monitor asystole Epinefrin/intravenous
A : cardiac arrest

Patient ROSC several times

03.40 The patient was decleared Death

 6th Patient Identity

Name : Mr. DR
Age : 50 yo
Address : Makassar
MR : 913441
Date of Admission : 8 March 2020
DPJP : dr AFG
 History Taking
• Chief complaint : shortness of breath
• Shortness of breath since 1 years ago, worsened 3 days
before admitted to the hospital. Continously. DOE (+) PND
(+) orthopneu (+). Chest pain (-). History chest pain (-).
There was palpitation, epigastric pain (-), Cough(+) since 1
years ago, white sputum, no blood, no fever, he is on
pulmonary tuberculosis treatment.
• History of Hypertension (-)
• History of diabetes mellitus (-)
• History of smoking (+) > 20 pcs/days for > 5 years
 Physical Examination
• BP: 128/84 mmHg, HR : 110-140 bpm irregular, RR : 30 tpm, T:
36.80C
• Conjunctiva not anemic, sclera not icteric
• JVP R+4 cmH2O (position 30◦)
• Vesicular breath sound, ronchi basal bilateral, wheezing (-)
• S1/S2 irregular irregular, murmur systolic grade 3/6 at Apex
and LLSB
• Warm extremities, extremities oedema (+) minimal
ECG at ER PJT
(8/3/2020)
 Lab. Findings (8/3/2020)

WBC 5.0 103/mm3 4-10 x 103/mm3

Neut/Lymph/Mono/Eo/Baso 84.0/5.8/9.4/0.6/0.2 %

HGB 11.3 g/dl 12-16

PLT 95 103/mm3 150-400 x 103/mm3
HCT 33 % 37-48 %
PT 13.5 Second 10-14
INR 1.32
APTT 34.7 second 22,0-30,0
SGOT 25 U/L < 38
SGPT 16 U/L < 41
Ureum 22 mg/dl 10-50
Creatinin 0.45 (eGFR: 131.9 mg/dl <1,1
ml/min)
RBG 104 gr/dl <140
Natrium 134 mmol/l 136 – 145
Kalium 4.5 mmol/l 3.5 – 5.1
Klorida 102 mmol/l 97 - 111
Chest X-Ray PJT
8-3-2020
Interpretation

• Dilatation Suprahilar with reticulogranular

spots at both of lung
• Cor enlarged with CTI 0,78 concave
cardiac waist with grounded apex
• Normal aortae
• Bone intact
• Soft tissue normal

-Conclusion :
•Cardiomegaly with sign of interstitial
oedema
•Pleural efussion dextra
 Echocardiography (8/3/2020)
Heart valves:
• Mitral: MR severe (MR ERO 0.46 cm2, MR vol 6 ml) Flail AML, restriction PML
• Aorta: 3 cuspis, calcification positive RCC, NCC, AR mild (AR PHT 844ms)
• Tricuspid : TR severe ( TR Vmax 4.03 m/s, TR max PG 65 mmHg)
• Pulmonal : PR Mild (PVAcct 10.54 m/s)
Dimension of heart chambers : dilatation of all chamber, LV D-shaped
• LA : LA major 7.6 cm, LA minor 5.0 cm
• LV : LVEDd 5.38 cm, LVEDs 3.62 cm
• RA: RA major 6.3 cm, RA minor 5.7 cm
• RV: RVDB 3.7 cm
• Aorta : Ao 3.2 cm, LA 5.6 cm, LA/Ao 1.75
• Normal left ventricular systolic function, Ejection Fraction 60.6 % (TEICH)
• Decreased right ventricular systolic function, TAPSE 1.3 cm
• Left Ventricular Hypertrophy : eccentric positive (LVMI 140 g/m2, RWT 0,34)
• Myocardial Movement : Paradoxical ivs movement
• eRAP : 15 mmHg (IVC expiration 2.8 cm, inspiration 1.7 cm)
• E/A on AF
Conclusion
• Normal LV systolic function, EF 60.6% (BIPLANE)
• Decreased RV systolic function, TAPSE 1.3 cm
• Dilatation all chambers, LV D shaped
• Eccentric LVH
• Paradoxical IVS movement
• MR severe, flail AML, restriction PML
• AR mild, TR severe, PR mild
 ASSESSMENT
• Atrial fibrillation rapid ventricular response
(CHA2DS2 VASc score 1, HAS BLED 0)
• Right Heart Failure
• Severe Mitral regurgitasi
• Severe Tricuspid regurgitasi
• TB paru on treatment intensive phase
• Trombositopenia
 Management
• Digoxin 0.5 mg/bolus/iv
• Furosemid 40 mg/bolus/iv
• Maintenance Furosemid 10 mg/hour/syringe pump
• Warfarin 2 mg/24 hours/oral
• Ramipril 2.5 mg/24 hours/oral
 Plan
• Transfer to HCU
• Consult to pulmonology
• Peripheral Blood Analysis
 Pulmonology division
• Assessment :
- Pulmonary Tuberculosis on treatment
- COPD

• Therapy:
– N Ace 200mg/8 hours/oral
– Combivent /8 hours/ inhale
– 4FDC 3 tab/24 hours/oral
– Paracetamol 1 g/8 hours/ drips
Plan :
- Thorax X- Ray
- Transfer to non isolated room
 7th Patient Identity

Name : ES
Age : 50 years old
Address : Bone
MR : 913440
Date of Admission : March 8th, 2020
DPJP : dr. AFG

The patient was referred from Hapsah Hospital, Bone

with diagnosis STEMI inferior onset < 12 hour
 History Taking
A 50 y.o man was admitted to PJT with Chest pain.

chest pain since 3 days ago, worsened 17 hours before admitted to PJT. Triggered
with activity, relieved with rest, pressed like sensation, duration < 20 minutes, no
diaphoresis. There was History of chest pain, intermittenly, aggravated by activity,
shortness of breathing (-). History of chest pain since 2 years ago and He had
Coronary Angiography at 2018. 1 week ago patient undergone treadmill test in Awal
Bros hospital with positive ischemic test.

There is no history of DM nor HT

No family history with cardiac disease

History of smoking (+) almost 20 years, stopped since 3 years ago

History medication at Hapsah hospital: Aspilet 160mg; Clopidogrel 300mg; Nitrokaf
retard 2,5mg; Bisoprolol 2,5mg ; Atorvastatin 20 mg
 Physical Examination
• BP: 116/60 mmHg, HR : 60 bpm regular,
RR : 20 tpm, T: 36.70C, O2 saturation 99%
room air
• Conjunctiva not anemic, sclera not icteric
• JVP R+2 cmH2O (position 30◦)
• Vesicular breath sound, rales (-), wheezing
(-)
• Regular I/II heart sound, murmur (-)
• Abdomen : peristaltic normal
• Extremities: warm, oedema (-)
ECG (7/3/2020) at Bone (onset 2 hour)
ECG (8/3/2020) at PJT (00.15)
Foto thorax (8/3/20)
• Normal bronchovascular
pattern of both lungs
• Cor : normal (CTI 0.48), aorta
normal
• Both sinus and diaphragm
normal
• Intact bones
• Normal soft tissue

Conclusion :
• Normal Chest X-Ray
Resting ecg at awal bros when patient treadmill 4/3/2020
Coronary Angiography (25/10/2018)
at Awal Bros Hospital, Makassar
 Echocardiography (8/3/2020)
• Cardiac Chamber
• Mitral : Normal function and movement
• Aorta : Normal function and movement
• Tricuspid : Normal function and movement
• Pulmonal : Normal function and movement
• Cardiac Dimension :
• LA : Normal, LA major 4.6 cm, LA minor 3.3 cm, LAVI 22.1 ml/m2
• LV : Normal, LVEDd 5.07 cm, LVEDs 2.09 cm
• RA : Normal, RA major 4.5 cm, RA minor 2.2 cm
• RV : Normal, RVDB 2.5 cm
• Aorta : Ao 3.2 cm, LA 3.5 cm, LA/Ao 1.09
• Normal left ventricle systolic function, Ejection Fraction 74.5% (TEICH), 68.1% (BIPLANE)
• Normal right ventricle systolic function, TAPSE 1.8 cm
• Left Ventricular Hypertrophy : (-) negative (LVMI 100 g/m2, RWT 0,38)
• Myocardial movement : Global Normokinetic
• eRAP 8 mmHg (IVC Exp 1.3 cm, Insp 0.7 cm)
• E/A on > 1, E’Med 7.06 cm/s, E’lat 10.3 cm/s, E/E’ 7.15

Conclusion :
•Normal LV systolic function, EF 68.1% (BIPLANE)
•Normal RV systolic function, TAPSE 1.8 cm
•Global Normokinetic
•Normal LV diastolic function
 Lab. Findings (8/3/2020)
WBC 5,57 4-10 x 103/mm3 103/mm3
N/L/M/E/B 47,0/38,4/10,1/3,8/0,7
HGB 14,8 g/dl 12-16
PLT 226 150-400 x 103/mm3
SGOT 19 <38 U/L
SGPT 21 <41 U/L
Ureum 11 10-50 mg/dl
Creatinin 0,80 eGFR 104,2 <1.3 mg/dl
RBG 82 <140 gr/dl
Sodium 141 136 – 145 mmol/l
Potassium 4,3 3.5 – 5.1 mmol/l
Chloride 106 97 – 111 mmol/
PT/APTT/INR 11,0/23,3/1,06 10-14/22-30 detik
HS Troponin I 3,3  <1.5 M (<17-50) ng/L
 Working Diagnosis
• Unstable Angina Pectoris (crescendo angina) low
risk (GRACE score 79 points, 2% probability of death from admission to
6 months. TIMI score 4 points, 20% risk at 14 days of: all-cause
mortality, new or recurrent MI, or severe recurrent ischemia requiring
urgent revascularization)
 Management
• NaCl 0,9% 500 cc/24hours/intravenous
• Fondaparinux 2,5mg/24hours/subcutan
• Aspilet 80 mg/ 24 hours/oral
• Clopidogrel 75 mg/ 24 hours/oral
• Atorvastatin 40 mg/ 24 hours/oral
• Isosorbid Dinitrate 5mg/sublingual if chest pain
 Plan:

• Invasive strategy
• Lipid profile examination
• Transfer to CVCU
 8th Patient Identity
Name : SB
Age : 66 years old
Date of Birth : 08-12-1954
Address : Makassar
MR : 913442
Date of Admission : March 8th, 2020
DPJP : dr. AFG

The patient was referred from Bhayangkara Hospital Mamuju with

diagnosis UAP, epilepsi, dispepsia
 History Taking

Chief Complaint : chest pain

• Since 5 days before admitted to PJT, induced with activity, pressed like sensation,
radiated to the back, duration >10 minutes, diaphoresis (+), not relieved with
rest, Nausea (+), vomitting (-). There was no shortness of breath. There was no
History of chest pain or SoB
• No history of hypertension and DM
• History of smoking , 1 packet per day.
• History of taking epylepsi medication since last month with depakene
• History of medications before referred from Mamuju are nitrokaf, cpg, and
simvastatin
 Physical Examination
• BP: 110/80 mmHg
HR : 88 bpm regular,
RR : 20 tpm
T: 36.50C
• Conjunctiva not anemic, sclera not icteric
• JVP R+1 cmH2O (position 45◦)
• Vesicular, no rales, no wheezing
• S1/S2 regular, gallop(-), no audible murmur
• Hepar/lien not palpable, normal peristaltic sound
• Extremities: warm, no oedema
ECG 06 March 2020 at Mamuju
ECG 08 March 2020 at PJT (03.15)
 Lab. Findings (08 March 2020)
WBC 10,91 103/mm3 4-10 x 103/mm3
N/L/M/E/B 75.5/11.1/12.2/0.8/0,9
HGB 12,6 g/dl 14-18
PLT 239 103/mm3 150-400 x 103/mm3
SGOT 18 U/L < 38
SGPT 23 U/L < 41
Ureum 7 mg/dl 10-50
Creatinin 0,6 eGFR 104.8 mg/dl <1,3
PT 11,4 s 10 – 14
aPTT 30,2 s 22.0 – 30.0
INR 1,10 -
RBG 85 gr/dl < 140
HS Troponin I 17,5 g/l 17-50
Sodium 138 mmol/l 136 – 145
Potassium 2,6 mmol/l 3.5 – 5.1
Clorida 105 mmol/l 97 - 111
Chest X-Ray 05 March 2020 at Mamuju

• Cor : enlargement cor with CTI 0,61 ;

raise apex and aortic dilatation
• Normal bronchovascular pattern
• Both sinus and diaphragms are
normal
• Intact bones

Conclusion :
Cardiomegaly with dilatation of aortae
 Echocardiography (08/03/2020)
• Cardiac Chamber
• Mitral : Normal function and movement
• Aorta : Normal function and movement
• Tricuspid : Normal function and movement
• Pulmonal : Normal function and movement
• Cardiac Dimension :
• LA : Normal, LA major 4.3 cm, LA minor 3.4 cm
• LV : Normal, LVEDd 5.26 cm, LVEDs 3.62 cm
• RA : Normal, RA major 4.4 cm, RA minor 3.5 cm
• RV : Normal, RVDB 2.5 cm
• Aorta : Ao 3.5 cm, LA 3.5 cm, LA/Ao 1.0
• Normal left ventricle systolic function, Ejection Fraction 58.5% (TEICH), 57.2% (BIPLANE)
• Normal right ventricle systolic function, TAPSE 1.9 cm
• Left Ventricular Hypertrophy : (+) concentric (LVMI 146 g/m2, RWT 0,49)
• Myocardial movement : Global Normokinetic
• eRAP 8 mmHg (IVC Exp 1.8 cm, Insp 1.0 cm)
• E/A on Fusion

Conclusion :
• Poor Echo Window
• Normal LV systolic function, EF 57,2% (BIPLANE)
• Normal RV systolic function, TAPSE 1,9cm
• LVH Concentric
 Assessments

• Unstable Angina Pectoris (New onset) low

risk (GRACE score 96 points, 3% probability of death from
admission to 6 months. TIMI score 2 points, 8% risk at 14 days of:
all-cause mortality, new or recurrent MI, or severe recurrent
ischemia requiring urgent revascularization)

• Hypokalemia
• Epilepsy
 Managements
• NaCl 0.9% 500 cc/24hours/intravenous
• Loading Aspilet 160mg/oral
• Loading Clopidogrel 300mg/oral
• Aspilet 80mg/24 hours/oral
• Clopidogrel 75mg/24hours/oral
• Farsorbid 10mg/8hours/oral
• Fondaparinux 2,5mg/24hours/sc
• Atorvastatin 40mg/24hours/oral
• KCl 25 meq in 500 ml NaCl 0,9% for 24 hours
 Plans
• Control electrolyte post correction
• Check lipid profile
• Consult to neurology department
• Transfer to HCU
 Neurology department
• Assessment:
– Hemiparese Sinistra Tipika et causa Post Stroke
– Post Generalized Tonic Clonic Seizure et causa
Susp. Epilepsy
• Therapy:
– Depacene syrup 5 ml / 12 hour / oral
– PDAK capsule / 12 hour / oral
– Vit B6 tablet / 24 hour / oral
 9th Patient

Name : Mr. A
Age : 43 years old
Address : Palopo
MR : 913448
Date of Admission : March, 8th2020
DPJP : dr AFG

Referred from Palopo Hospital with diagnosed STEMI

Whole Anterior Wall onset > 12 hours
 History Taking
A 43 y.o man was admitted with Chest pain
It was felt since 7 days before admitted to PJT, pressed-like sensation. Duration was more than 30 minutes
with VAS 7/10 and not relieved with resting. Diaphoresis (+), nausea (+) and vomiting (-). When he came to
PJT, his vas score was 1/10. There was shortness of breath since 2 days before admitted to PJT, DOE (-),
PND (-), orthopneu (-). History of chest pain (+) 1 month ago, intermitten. History of shortness of breath
(-). Cough (+) for 3 days, white sputum, Fever (+) for 5 days intermitten.
Coronary Risk Factor:
• History of hypertension (-)
• History of DM (-)
• History of smoking (+) 32 pcs/day. For > 5 years
• Family history of cardiovascular disease (-)
• History of medicine from Palopo Hospital : Miniaspi 80mg, Clopidogrel 75 mg, Bisoprolol 2,5 mg,
Rosuvastatin 40mg, Ramipril 2,5 mg, N-Ace 200mg, Paracetamol 500mg, Cedocard 1mg/hour/SP,
Arixtra 2,5mg/24 hours/subcutan was given for 5 days.
 Physical Examination
• BP: 107 / 63 mmHg, HR : 106 bpm regular, RR : 22
tpm, T: 37,50C,
• Conjunctiva not anemic, sclera not icteric
• JVP R+2 cmH2O (position 30◦)
• Vesicular breath sound, Ronchi (-), wheezing (-)
• S1S2 regular heart sound, Murmur (-)
• Extremity: warm, No pretibial oedema
ECG at Palopo Hospital (7/3/2020)
(5.45)
ECG at PJT (8/3/2020)
4.53
 Lab. Findings (8/3/2020)
WBC 12.3 103/mm3 4-10 x 103/mm3
N/L/M/E/B 76.2/12.4/10.3/0.7/0.4 %
HGB 13.7 g/dl 14-18
PLT 293 103/mm3 150-400 x 103/mm3
SGOT 28 U/L < 38
SGPT 36 U/L < 41
Ureum 32 mg/dl 10-50
Creatinin 0.86 e GFR 106.2 mg/dl <1,3
PT 10.3 10 – 14s
aPTT 32.4 22.0 – 30.0s
INR 0.99 -
Natrium 137 mmol/l 136 – 145
Kalium 4.3 mmol/l 3.5 – 5.1
Klorida 103 mmol/l 97 – 111
GDS 117 mg/dl 140
Hs Troponin I 18651.8 ng/l L= 17-50
 Echocardiography (8/3/2020)
• 1. Valves :
• Mitral : MR mild (MR ERO 0.1 cm2 MR VOI 10 ml)
• Aorta : 3 cuspis, calcification (+), RCC, normal function and movement
• Tricuspid : normal function and movement
• Pulmonal : normal function and movement PV ACCT 95 ms
• 2. Cardiac chambers dimension :
• LA : normal, LA mayor 4.8 cm, LA minor 3.5 cm, LAVI 38,8 ml/m 2
• LV : normal, LVEDd 5.03 cm, LVEDs : 4.12 cm
• RA : normal, RA mayor 4.2 cm, RA minor 4.2 cm
• RV : normal, RVDB 2.7 cm
• Aorta : normal, Ao 3.2 cm, LA 3.5 cm, LA/Ao 1.09
• 3. Decreased Left Ventricle systolic function, Ejection Fraction 37.4 % (TEICH), 32.71 % (BIPLANE)
• Normal Right Ventricle systolic function, TAPSE 2.0 cm, S’ lateral velocity 16.1 cm/s
• 4. Left Ventricular Hypertrophy (+) concentric (LVMI 135 g/m2, RWT 0.49)
• 5. Myocardial movement : akinetic mid basal anterior, apicoanterior, hypokinetic mid basal antero septal,
anterolateral, apicoseptal, apicolateral.
• 6. eRAP : 8 mmHg (IVC exp : 1.6 cm, IVC insp : 1.0 cm)
• 7. E/A >1 E’ Med velocity 5.8cm/s E/E’ Average : 15.9 cm/s E’ lateral velocity 6.61 cm/s
• 8. LVSV : 41 ml, LVCO : 4.2 l/min, LVOTVTI : 13.2 cm
• Conclusion :
• Decreased LV systolic function EF 32.7% (BIPLANE)
• Normal RV systolic function, TAPSE 2.0 cm
• Concentric LVH
• MR Mild
• Akinetic and hypokinetic segmental
• Grade II diastolic dysfunction
FOTO THORAX (8/3/2020)
• Hazzines on parahillar
and paracardial
• Cor enlarged with CTI
0,54 concave cardiac
waist with grounded
apex
• Normal aorta
• Normal both sinuses and
diaphragm
• Intact bones

Conclusion :
• Cardiomegaly with
sign pulmonary
oedema
• bronchopneumonia
 Working Diagnosis
• Recent STEMI extensive anterior KILLIP 1
(TIMI Score 5 points. 12% risk of all cause
mortality at 30 days)
• Community acquired pneumonia CURB 65
score 0
 Management

• Natrium Chlorida 0.9 % 500cc/24 hours/drips

• Miniaspi 80 mg/24 hours/oral
• Clopidogrel 75 mg/24 hours/oral
• Rosuvastatin 40 mg/24 hours/oral
• Ramipril 2,5 mg/24 hours/oral
• Bisoprolol 2.5mg/24 hours/oral
• N-Ace 200 mg/8 hours/oral
• Paracetamol 500 mg/8 hours/oral
• Farsorbid 10mg/8 hours/oral
• Ceftriaxon 2gr/24 hours/ iv
 Plan:

Transfer to CVCU
Check lipid profile
Consult to pulmonology
 Pulmonology division
• Assessment :
• Planning:
Thank You