CBD

(CASE BASED DISCUSSION)

A–55 years old woman with chest pain

Presented by :
Nadhir Athaya Windasari
30101407257

Advisor :
dr. H. M. Saugi Abduh, Sp.PD, KKV, FINASIM
Patient Identity
 Name : Mrs.S
 Age : 55 years old
 Gender : Female
 Religion : Moslem
 Job : Unemployed
 Address : Kp.Kalijorong RT 2 RW 3, Kedungjati - Grobogan
 MR Number : 01-32-76-97
 Room : Baitul Izzah 1
 Entry Date : June 23 rd, 2019
 History Taking

Main Problem • Chest pain

• The patient was admitted to the ER of Sultan Agung Islamic Hospital

due to a tight chest pain on her left chest. About 12 hours before the
admission, she suddenly felt chest pain when she was laying down
after praying. The pain lasted for more than 20 minutes, radiating to
History of
the upper left limb and her jaw followed by shortness of breath. She
Present Ilness
admit the pain didn’t get any better when she rested.
• She complained no vomiting and nausea, no abdominal pain and
syncope. She also got her last period on the age of 50. She doesn’t
smoke or drink alcohol.
 Systematic Anamnesis

 Main Complain : Chest pain

 Onset : 12 hours before admission
 Location : Left chest
 Quality and Quantity : The pain felt like tightness and lasted for more than 20
minutes, radiating to the upper left limb and her jaw followed by shortness of breath.
 Chronology : The pain was felt suddenly when she was laying down after praying.

 Modification factor :-
 Comorbid complains : Shortness of breath
 History of Illness
History of Previous
Illness

• Cardiovascular disease (+)  She is taking some medicines from the previous doctor :
a. Nitroglycerin 2 x 2,5 mg (p.c)

• Hypertension (+)  She is taking some medicines from the previous doctor :
a. Candesartan 1 x 16 mg (p.c)
b. Carvedilol 2 x 25 mg (p.c)
c. Nifedipine 1 x 30 mg (p.c)

• Diabetes Mellitus (+)  She is taking some medicines from the previous doctor :
a. Glimepiride 1 x 1 mg (ac)

• Allergy (+) : Antalgin

• Asthma (-)
 Family History Socio-Economic History

• Hypertension history (-)

• Hospital cost certified by “BPJS-PBI”
• DM history (-)
and member of PROLANIS.
• Cardiovascular disease (+)
• She lives with her family and currently
babysitting her 2 years old grandchild.
• She doesn’t smoke and drink alcohol.
PHYSICAL EXAMINATION
 GENERAL STATUS
• General : Weakness
• Awareness : Compos mentis (GCS 15)
• Anthropometric Status
• Weight : 62 kg
• Height : 158 cm
• BMI : 24,8 kg/m2

Vital Sign
• BP : 160/100 mmHg
• HR : 80 x /minute
• RR : 20 x /minute
• Temp : 36,4⁰C Interpretation:
Hypertension
 PHYSICAL EXAMINATION

 Skin : plakat (-) eritematous (-), jaundice (-)

 Head : Mesocephal
 Eyes : blurred vision (-), red eyes (-), icteric sclera (-/-)
 Ears : hearing loss (-), ring (-), discharge (-)
 Nose : nosebleed (-), discharge (-)
 Mouth : cyanosis (-), thrush (-), bleeding gums (-)
 Throat : pain swallow(-), hoarseness (-), odinofagia (-)
 Neck : enlargement of the gland (-), JVP (-).

INTERPRETATION : NORMAL
 LUNG EXAMINATION

EXAMINATION ANTERIOR POSTERIOR

Inspection - Static RR : 20x/min RR : 20x/min
Thoracal breathing Thoracal breathing
Hyperpigmentasi (-) Hyperpigmentasi (-)
Spider nevi (-) Spider nevi (-)
Atrofi M. Pectoralis (-) Hemithoraks D=S
Hemithoraks D=S ICS Normal
ICS Normal Diameter AP < LL
Diameter AP < LL
Inspection - Dinamic Up and down of hemitoraks D=S Up and down of hemitoraks D=S
Muscle retraction of breathing (-) Muscle retraction of breathing (-)
Retraction ICS (-) Retraction ICS (-)
 EXAMINATION ANTERIOR POSTERIOR
Palpation Palpation pain (-) Palpation pain (-)
Mass (-) Mass (-)
Sterm fremitus D=S Sterm fremitus D=S
Percution Sonor (+) Sonor (+)
Auscultation Vesicular (+) Vesicular (+)
Whezzing (-) Whezzing (-)
Ronchi (-) Ronchi (-)

INTERPRETATION : NORMAL
 CARDIAC EXAMINATION
Inspection : Ictus cordis isn’t seen.
Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-), sternal lift (-)
Percussion  :
 Upper borderline of heart : ICS II left sternal line
 Waist of heart : ICS III left parasternal line
 Lower right borderline of heart : ICS IV right sternal line
 Lower left borderline of heart : ICS VI, 2 cm lateral from left mid clavicle line
Auscultation
 Aortal valve : S1 & S2 standard, additional sound (-)
 Pulmonary valve : S1 & S2 standard, additional sound (-)
 Tricuspid valve : S1 & S2 standard, Murmur sound (-)
 Mitral valve : S1 & S2 standard, Murmur sound (-)

Interpretation : Cardiomegaly
 ABDOMEN EXAMINATION

 Inspection : Symetric, sycatric (-), striae (-), enlargement of vena (-), caput medusa (-).
 Auscultation : peristaltic (+)
 Palpation
- Superfisial : tight (-), mass (-), pain (-)
- Deep : 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
- Kidney : Costovertebra Pain (-) Interpretation : Normal
 EXTREMITIES EXAMINATION

Ekstremitas Superior Inferior

Oedema -/- -/-

Cold -/- -/-

Jaundice -/- -/-

Interpretation : Normal
LABORATORY TESTS
 HAEMATOLOGY TEST
June, 23rd 2019

Hematology Result Normal

Routine Blood 1

Hemoglobin (g/dl) 13,4 11,7-15,5

Hematocrit (%) 41,3 33 - 45

Leucocyte (thousand/uL) 5,54 3.8 – 10.6

Thrombocytes (thousand/uL 254 150 - 440

Interpretation:
Normal Hematology test
 LABORATORY TEST
June, 23rd 2019
Kimia Result Normal
Natrium (mmol/L) 140.8 135-147
Kalium (mmol/L) 3.67 3.5-5
Chloride (mmol/L) 102.2 95-105
GDS (mg/dL) 110 75-110
Ureum (mg/dl) 21 10-50
Creatinin (mg/dl) 0.71 0.6-1.1
High Sensitive Troponin I (ng/L) <1,5 <19 ng/L)

Interpretation : Normal
 LABORATORY TEST
June, 25th 2019

Kimia Result Normal

Cholestrol 105 <200
Trigliserid 98 <160
HDL Cholestrol Direct 27 37-92
LDL Cholestrol Indirect 64 60-130
Uric Acid 3,7 2,6 – 5,7

Interpretation : Low HDL level

 CHEST X-RAY

• Cor :
1. Apex to laterokaudal
2. Arc aortic elongation

• Pulmo :
1. Vascular expression does not increase
2. There is no infiltrate
3. Right and left costophrenic angles are sharp
4. Diaphragm is normal

Impression:
1. Cardiomegaly (LV)
2. Arc aortic elongation
3. There is no infiltrate in pulmo
ECHOCARDIOGRAPHY
ECHOCARDIOGRAPHY :
Global Normokinetic
Normal LV +RV systolic function
Dysfunction of LV dystolic
LA dilatation, Hypertrophy of IVS
ECG : June 23rd 2019
 Interpretation
• Rhytm : Junctional
• Regularity : Regular
• Frequency : 125 bpm
• Axis : LAD
• Transision Zone : V5
• P Wave : Can’t be defined
• PR interval : Can’t be defined
• QRS Complex : 0.08 seconds (normal)
• LVH : (-)
• RVH : (-)
• Q Wave : normal
• ST Segment : (-)
• T wave : T inversion on lead II, lead III and aVF

Interpretation : Inferior Ischemia

ECG : June 25th 2019
 Interpretation
• Rhytm : Sinus
• Regularity : Regular
• Frequency : 68
• Axis : LAD
• Transition Zone : V4
• P Wave : 0.12 seconds (normal)
• PR interval : 0.20 (normal)
• QRS Complex : 0.12 (normal)
• LVH : (-)
• RVH : (-)
• Q Wave : normal
• ST Segment : (-)
• T wave : normal
Interpretation : NSR, LAD
 ABNORMAL DATA

HISTORY TAKING
1. Chest pain
CHEST X-RAY ECG
2. Shortness of breath
3. History of Diabetes Mellitus 8. Cardiomegaly 11. Inferior Ischemia
4. History of Hypertension 9. Arc aortic elongation 12. LAD
5. History of cardiovascular disease

ECHO
PHYSICAL EXAMINATION 13. Global Normokinetic
LABORATORY TEST
6. BP : 160/100 mmHg 14. Normal LV +RV systolic function
10. Low HDL level
15. Dysfunction of LV dystolic
7. Cardiomegaly 16. LA dilatation, Hypertrophy of IVS
 PROBLEM LISTS

Acute Coronary
Syndrome Hypertension Heart
Disease

History of Diabetes
Mellitus
 ACUTE CORONARY SYNDROME

1. Assessment
3. Initial Plan of Treatment
UAP
 Oxygen
NSTEMI
 Bisoprolol 2,5 mg x 1
2. Initial Plan of Diagnosis  ISDN subling 5 mg x1
 TIMI Score (Recurrent CVD Events) – 3 (moderate risk)  Clopidogrel 75 mg x1
 GRACE Score (Mortality in hospital) – 55 (mortality risk
<1%)  Aspilet 80 mg x1
 CRUSADE Score (Bleeding Risk) – 41 (Moderate risk)  Fondaparinux sodium inj 1 x 2,5 mg
because of dual antiplatelet and anti koagualan  major
bleeding
4. Initial Plan of Monitoring
 ECG
 Troponin I
 clinical manifestation

5. Initial Plan of Education

• Explain to patient about the disease
• Reducing emotional stress
• Routine drugs consumption
• Routine medical check up
 HISTORY OF DIABETES MELLITUS

1. Assessment
2. Initial Plan of Diagnosis
Complication
• Blood Glucose
 Acute Complication : Hypoglycemia
• EMG
 Chronic Complication :
• Micral test
Macrovaskular : Cardiovascular disease
• Funduscopy
Mikrovaskular :
neuropathy diabetic  first complication
retinopathy diabetic
nefropathy diabetic
3. Ip. Tx
• Lifestyle management
• Medical nutrition therapy
• Glimiperide 1 x 1 mg

4. Ip. Mx
• Blood glucose
• HbA1C

5. Ip. Ex
• Explain to patients about the condition and complication that may occur
• Controlling dietary habits
• Reduce glucose intake
• Exercise with CRIPE methods
 HYPERTENSION HEART DISEASE

1. Assessment:
 IP Mx :
Anatomy : Cardiomegaly, aortic elongation
Vital sign
Risk factor cardiovascular
 IP Ex :
Modifable : dislipidemia, DM, hiperuresemia  Control blood glucose and lipids 

IP Dx : profil lipid (LDL, HDL, TG, Total Cholestrol),  Eat healthy

 Reduce sodium intake to no more than 2,400
GDS, Uric Acid
mg/day 
IP Tx :  Moderate-to-vigorous activity 3-4 days a week
averaging 40 min per session. 
 Imidapril 1 x 5 mg

 Amlodipin 1 x 5mg
Click icon to add picture

ACS
TIMI
GRACE
CRUSADE
Click icon to add picture

HYPERTENSION
Click icon to add picture

DIABETES MELLITUS