Morning Report

Saturday, August 11th 2018

Multazam
Randy
Maya
Fidya
Henry
Wia
Wiwi
1st Patient
Name : Tn. AB
Date of Birth : 27-09-1978 (40 y.o)
Address : Soppeng
Date of Admission : August 11th, 2018

DPJP : IM

Patient was referred from Soppeng Hospital with diagnose

Anterior Myocard Infarct + Total AV Block
 History Taking
Chief Complaint : Chest Pain
• Chest pain was felt suddenly, pressed-like sensation, radiated to the neck and
left arm. It was felt since 13 hours before admission, duration >20 minutes and
accommpanied by diaphoresis. There was no nausea and vomiting. Three days
before he was felt the same complaint while playing football. There was no
history of chest pain or complaint shortness of breath before. Coronary risk
Factor :

– History of smoking >20 years, 1 pack/day

– There was no history of diabetes mellitus or hypertension

From referral hospital patient already given : Aspilet 160mg, Clopidogrel 300mg,
Nytroglycerin 10mcg/min/sypump
 Physical Examination

• BP: 120/80 mmHg, HR : 96x/m regular, RR : 24 tpm, T:

36,50C, O2 saturation 91%
• Conjunctiva not anemic, sclera not icteric
• JVP R+3 cmH2O
• Vesicular breath sound, rales at base of both lungs, no
wheezing
• S1/ S2 Regular, no murmur
• Normal Peristaltic, hepar and lien unpalpable
• Extremity: warm, no edema
 ECG at Soppeng Hospital
11/8/2018
(03.30)

Ventricular escape rhythm, atrial rate ~ 65 bpm, ventricular rate ~ 46 bpm, axis 7 degree, A-V
dissociation, ST Elevation V2-V4
Conclusion : Ventricular escape rhythm, normoaxis, acute anterior wall MCI, Total AV
Block
 ECG at Cardiac Center
11/8/2018
(15.30)

Sinus Rhythm, HR 93 bpm, axis 0°, P wave 0,04 s, QRS 0,16s, ST Elevation in V2-V4, wide
slurred S wave V5-V6, T inversion V1-V3
Conclusion : Sinus Rythm, normoaxis, acute anterior wall MCI, CRBBB
ECG at Cardiac Center
11/78/2018
(20.30)
 ECG at Cardiac Center
11/8/2018
(23.00) post TAVB

Sinus Rhythm, HR 92 bpm, axis 0°, P wave 0,04 s, QRS 0,16s, ST Elevation in V2-V4, wide
slurred S wave V5-V6, T inversion V1-V3
Conclusion : Sinus Rythm, normoaxis, acute anterior wall MCI, CRBBB
GAMBAR INI KEPOTONG V1 NYA
 Laboratory Findings
11/08/2018

WBC 17,8 103/mm3 4-10 x 103/mm3

N/L/M/E/B 74.3/14,6/10,2/0,5/0,4
HGB 14,2 g/dl 12-16
HCT 40 % 37,0-48,0
PLT 286 103/mm3 150-400 x 103/mm3
GDS 104 mg/dl 140
SGOT 245 U/L < 38
SGPT 136 U/L < 41
UREUM 22 mg/dl 10-50
KREATININ 0,81 mg/dl L(<1,3) P<(1,1)
eGFR 111,2 mL/min
PT/APTT 10,4/22,9 second 10-14/22,0-30,0
INR 0,98 - -
Na 133 mmol/L 136-145
K 4,2 mmol/L 3,5-5,1
Cl 100 Mmol/L 97-111
CK 1190,63 U/L L<190 P<167

CKMB 86,2 U/L <25

TROP I >10,0 ng/ml <0,01
Chest Xray
11/08/2018

• Normal bronchovascular marker

• Cor enlarged with CTI 0,6, conveks
cardiac waist with downward apex, aorta
dilatation and elongation
• Consolidation homogen that cover sinus
costophrenicus left diaphragm
• Normal right sinus costophrenicus and
diaphragm
• Intact Bone
Conclusion :
• Cardiomegaly with dilatatio et
atherosclerosis aortae
• Left Pleural Efusion
 Echocardiography
11-08-2018
• Decreased Systolic Function of LV, EF 35,1 % (Teich) 32,8 % (Biplane)
• Normal Cardiac Chamber : (LVEDd : 4,7 cm, LVEDs 3,9 LA Mayor : 5,8 cm, LA Minor : 3,3 cm,
• RA Mayor 4,5 cm, RA Minor 2,7 cm, RVDB 2,8 cm, Ao 3,1 cm, LA 3,7 cm, LA/Ao 1,1)
• Left ventricle hypertrophy: Concentric (LVMI 151 g/m2, RWT 0,67)
• Myocardial Movement : Midbasal anterior, anteroseptal, inferoseptal, anterolateral, apicoanterior,
apicolateral
• Normal RV systolic function, TAPSE 1,9 cm
• Cardiac Valves :
• Mitral : Normal
• Aorta : Normal
• Tricuspid : Normal
• Pulmonal : Normal
• E/A >1
• eRAP 8 mmHG IVC E/I = 1,5cm/0,7cm
• LVCO 3,3 L/min
• LVSV 34 ml
• SVR 2117 dyne/s/cm⁵
Conclusion
• Decreased Systolic Function of left ventricle with EF 32,8 % (Biplane)
• LVH Concentric
• Akinetik segmental
• Left Ventricle Diastolic Dysfunction grade 2
 Assessment

• ST Elevation Myocardial Infarct Anterior Wall onset >12

hours Killip II (TIMI score 6 Estimated 30 Day Mortality
was 16,1%) with Right Bundle Branch Block

• Total AV Block

• Congestive Heart Failure NYHA II

 Management

• IVFD NaCl 0,9% 500 cc/24 hours/intravenous

• Aspilet 80 mg/24 hours/oral
• Clopidogrel 75 mg/24 hours/oral
• Enoxaparin 60 mg/12 hours/subcutan
• Nitroglycerin 10 mg/minutes/syringe pump
• Furosemid 40 mg/12 hours/intravenous
• Captopril 12,5 mg/8 hours/oral
• Atorvastatin 40 mg/24 hours/oral
• Alprazolam 0,5 mg/24 hours/oral

• Dopamin 5mcg/kgbb/minute/syringe pump

• External pacemaker
 Plan

• Transfer to CVCU
• Routine primary PCI strategy
• Temporary pacemaker
2nd Patient
Name : Tn. ARL
Date of Birth : 30-05-1956 (62 y.o)
Address : Makassar
Date of Admission : August 11th, 2018

DPJP : ZD
 History Taking
Chief Complaint : Shortness of breath
A 62 y.o man was admitted with complaint shortness of breath. There was
history of shortness of breath intermittenly since 1 months ago, worsening since
1 week ago, induced by mild activity. He has to sleep with 3 pillows. There was
history of fever and cough since 3 days ago. There was no history of chest pain.

There was history of heart disease since 10 years ago not regularly take
medication

There was history hypertension and diabetes mellitus since 10 years ago not
regularly take medication

There was no history of smoking

 Physical Examination

• BP: 170/100 mmHg, HR : 94x/m regular, RR : 22 tpm, T:

36,5C,
• Conjunctiva not anemic, sclera not icteric
• JVP R+4 cmH2O (position 300)
• S1/2 regular, no murmur
• Vesicular breath sound, rales at midbase of both lungs, no
wheezing
• Extremity: warm, edema (+)
 ECG at Cardiac Center
11/8/2018
(14.40)

Sinus Rhythm, HR 100 bpm, axis-5◦, P wave duration 0,08s, PR interval 0.16s, QRS duration
0,04s, poor R wave in V1-V3, S in V1+ R in V5 > 35 mm
Conclusion : Sinus rhythm, normoaxis, Anteroseptal ischaemic, LVH
 Laboratory Findings
11/08/2018
WBC 13,8 103/mm3 4-10 x 103/mm3

N/L/M/E/B 75,0/17,0/5,5/2,1/0,4

HGB 15,4 g/dl 12-16

MCV/MCH/MCHC 89/33/37

HCT 41 % 37,0-48,0

PLT 352 103/mm3 150-400 x 103/mm3

GDS 198 mg/dl 140

SGOT 10 U/L < 38

SGPT 11 U/L < 41

UREUM 52 mg/dl 10-50

KREATININ 1,45 mg/dl L(<1,3) P<(1,1)

eGFR 51,2 mL/min

PT/APTT 10,3/27,2 second 10-14/22,0-30,0

INR 0,97 - -

Na 136 mmol/L 136-145

K 4,2 mmol/L 3,5-5,1

Cl 98 Mmol/L 97-111
Chest Xray
11/08/2018

• Normal bronchovascular marker

• Cor enlarged with CTI 0,64, conveks
cardiac waist with downward apex, aorta
dilatation and calcification
• Normal both sinus costophrenicus and
diaphragm
• Intact Bone
Conclusion :
• Cardiomegaly with dilatatio et
atherosclerosis aortae
 Echocardiography
11-08-2018
• Decreased Systolic Function of LV, EF 40,9 % (Teich) 37,2 % (Biplane)
• Cardiac chambers : LA and LV dilatation (LVEDd : 5,5 cm, LVEDs: 4,4 LA Mayor : 7,1 cm, LA Minor : 4,5 cm, RA
Mayor 5,0 cm, RA Minor 3,5 cm,RVDB 2,8 cm, A0 3,7 cm, LA 3,8 cm. LA/Ao 1,0
• Left ventricle hypertrophy: Eccentric (LVMI 148 g/m2, RWT 0,4)
• Myocardial Movement : Hypokinetic basal mid anterior, anteroseptal, anterolateral, inferoseptal, apicoseptal
• Normal RV systolic function, TAPSE 1,9 cm
• Cardiac Valves :
– Mitral : Mild to moderate Mitral Regurgitation (MR ERO 0,34 cm² (MR Vol 35 ml)
– Aorta : 3 cuspis. Calcification (+), RCC, LCC, AR Trivial
– Tricuspid : TR mild (TR VMax 281 cm/s, TR Max P6 32 mmHg
– Pulmonal : Normal
• E/A > 1
• eRAP 3 mmHG LVSV 44 ml, LVCo 3,8 L/m SVR 2254 dyne/s/cm⁵
• Posterior pericardial Efusion = 1,7cm, lateral 0,8cm

Conclusion
• Decreased Systolic Function of left ventricle with EF 37,2 % (Biplane)
• LA and LV dialted
• Eccentric Left Ventricle Hypertrophy
• Segmental hypokinetic
• Mild to moderate Mitral Regurgitation
• Mild Tricuspid Regurgitation
• Left Ventricle Diastolic Disfunction grade 2
 Assessment

• Congestive Heart Failure NYHA III

• Coronary Artery Disease
• Hypertension Heart Disease
• Diabetes Mellitus Tipe 2
 Management

• Furosemide 40 mg/12 hours/intravenous

• Aspilet 80mg/24 hours/oral
• Candesartan 8mg/24 hours/oral
• Metformin 500mg/8 hours/oral
• Simvastatin 20 mg/24 jam/oral
• Bromhexin 1 tab/8 hours/oral
• Paracetamol 500mg/8 hours/oral
 Plan

• Transfer to ward
• GDP, GD2PP, HbA1c, lipid profile examination
• Consult to Endocrine Metabolic Department
THANK YOU