Coronary Artery Disease Double Vessels Disease,

Culprit Lesion Occlusion Thrombus with

Paroxysmal Supraventricular Tachycardia (PSVT)
Presented by :
Angnes Dera Mustika (I11110001)

Preceptor:
dr. Prihati Pujowaskito, Sp.JP(K), M.MRS
IDENTITY

Patient Name : Mr. ES

Room : Ciremai
Med.Rec Number : 424399
Sex : Male
Age : 72 y.o
Religion : Islam
Occupation : Unemployed
Address : Cihanjuang RT 01/07
Date of entry : March, 2th 2017
Chief Complaint :
Shortness of Breath

Present Illness :
Patient came to ER with shortness of breath since 2 days
before admition and got worse. Patient felt shortness of
breath even in daily activity. Pasien also felf chest pain like
a heavy weighted objects penetrating to his back.
Complaints are not accompanied by vomiting, cough,
sniffles, and fever. There is no swelling in the legs. Bowel
and bladder patient is normal.
Past Medical History
Patients had a history of high blood pressure but uncontroled.
Familys Disease History
Patients family does not have a similar disease with
patients
There are history of hypertension in the family
Lifestyle
Patients have history as a smoker, but has stopped
since 5 years ago.
Patient loves to eat salty, sour, hot and fatty food
Rarely having sports activity
PHYSICAL EXAMINATION

A. General Conditions
Awareness : compos mentis B. Vital Signs
Height : 160 cm Blood pressure : 120/90 mmHg
Weight : 62 kg Pulse : 150 x / mins
Nutrition level : Normal Respiration : 32 x / mins
Temperature : 36.8 C
SpO2 : 95 %
C. Review of System 2. Neck
1. Head a. Inspection
a. Skull : Normocephal - Trachea : Deviation (-)
b. Face : Puffy Face (-) - Thyroid gland : Not seem enlarge
c. eyes: - Lymph Nodes : Not seem enlarge
- Eyelids : eyelid edema - / - - Widening of vein: Not visible
- Sclera : icteric - / - b. Palpation
- Conjunctiva : anemic - / - - Thyroid gland : No enlargement
- Pupil : Round, Isokor - Lymph nodes : No enlargement
- Eye Lens : Clear - Tumours : None
d. Ears : There is no - Stiff neck : No
abnormalities - Jugular venous pressure: 5 + 2 cmH2O
e. Nose : There is no - HJR : None
abnormalities
f. Mouth: 3. Armpit: no abnormalities
- Lips : No abnormalities
- Gums and teeth: No abnormalities
- Tongue : No abnormalities
- Oral cavity : No abnormalities
- Neck cavity: There is no
4. Thorax Percussion
- Percussion comparison: sonor /
Inspection
sonor
- Shape : Symmetric
- Heart Boundaries :
- Movement : Symmetric
Left = ICS V left axillaris
- Intercostal space : Normal
anterior line
- Skin : No abnormalities
Right = ICS IV right sternal line
- Musculature : No abnormalities
- Ictus cordis : Not visible
Auscultation
- Mammae : No abnormalities
- Respiratory Sounds: VBS, Rh (+/+)
Palpation
- Skin : No abnormalities
- Vocal resonance: normal / normal

- Musculature : No abnormalities - Heart sounds: S1 & S2 regular

- Intercostal space : No abnormalities murmur (-), gallop (-)
- Vocal Fremitus: No abnormalities
- Ictus cordis : Impalpable
5. Abdomen

Inspection palpation
Shape: Flat Abdominal wall: Soepel
Skin: No abnormalities Tenderness: none
Umbilicus: indented
auscultation Mass / tumor: none
Bowel: (+) normal, 8 times / mins Hepar: no palpable
Bruit: None Spleen: no palpable
Troube space: empty
Kidney: Ballotement - / -
6. Extremities

CRT <2 sec

Warm extremities
Edema -/-
Laboratory Finding
Lab (02/03/2017) Value

Creatinin 1,4 mg/dl

CKMB 25 U/L

Lab (03/03/2017) Value

CKMB 60 U/L
ECG (2/3/2017) in ER

Rhythm : Arrhythmia
HR : 160x/minutes
Axis : Normoaxis
Abnormallities : Pathologic Q in lead III, aVF, V1-V4
Poor R Wave Progression
ST Elevation in lead III, aVF, V1-V4
ST Depretion di lead I, aVL, V5,V6
Conclusion : SVT with STEMI anteroseptal and STEMI inferior
ECG (2/3/2017) in ICCU

Rhythm : Arrhythmia
HR : 155x/minutes
Conclusion : Supraventricular Tachycardia
ECG (4/3/2017) in ICCU

Rhythm : Sinus
HR : 99x/minutes
Axis : Normoaxis
Abnormallities : Pathologic Q in lead III, aVF, V1-V4
Poor R Wave Progression
ST Elevation in lead III, aVF, V4
Conclusion : STEMI inferior and OMI anteroseptal
ECG (6/3/2017)

Rhythm : Arrhythmia
HR : 151x/minutes
Conclusion : Supraventricular Tachycardia
DCA
(6/3/2017)

Conclution:
CAD double vessel disease, culprit
lesion occlution thrombus di Mid RCA
Diagnosis
Clinical Dianosis :
Acute Pulmonary Edema + Acute Coronary Syndrom + Paroxysmal
Supraventricular Tachycardia

Anatomical Diagnosis :
Infark miokard inferior dan anteroseptal

Etiologic Diagnosis :
Atherosckerosis
Therapy
Nonpharmacologic Therapy
Bed rest
O2 2-4 lpm via nasal canula
IVFD NaCl
Monitoring ECG
Folley Catheter
Therapy

Pharmacologic Therapy

Inj Furosemid 2 amp 3x2 ampul

Clopidogrel 1 x 75mg PO
Tricagelor 2 x 90 mg PO
Aspillet 1 x 80 mg PO
Aspillet 2 x 80 mg PO
Inj Enoxaparin 2 x 0,6 cc SC
Bisoprolol 1 x 2,5 mg PO
Nitrogliserin 20 mcg/minute
Valsartan 1 x 40 mg PO

Inj furosemid 1 x 1 ampul

PCI
Atorvastatin 1 x 20 mg PO
DES (Drug-eluting Stents) in Mid RCA

Inj Amiodarone 150 mg in 10 minute

Prognosis

Quo ad vitam : Dubia ad malam

Quo ad sanactionam : Dubia ad malam
Quo ad Functionam : Dubia ad malam
THANK YOU