Patient’s Identity

Name : Mrs NDP

Date of birth : 12/05/1971
Age : 48 years old
Gender : Female
Occupation : Housewife
Admitted on : 25th August 2019
History taking
Chief complaint : Palpitation
History of disease : Female patient, 48 years old was admitted to emergency
room PJT with complaint of palpitation since 2 weeks ago. Patient also
complaint with chest pain with duration less than 20 minutes, she felt a sharp
pain protrude through her chest, not radiated. Cold sweat (+). History of chest
pain(-).
Pain at epigastrium (-). Nausea (-), vomit (-) Dyspneu (-) History of dyspneu(-).
History of hypertension (-). History of heart problem (-) Diabetes mellitus (-)
Family history of heart problem (+) Smoking (-)
She was a transferred patient from RS Grestalina with early diagnosed
Supraventricular Tachycardia. During at RS Grestalina, she was treated with
Candesartan 8 mg, Simarc 2 mg, Amiodarone 200 mg, Spironolactone 25 mg,
Mefenamic acid 500 mg, Furosemide 40 mg, Bisoprolol 5 mg.
 Physical Examination
General Status Vital Signs
• General appearance : moderately • Blood pressure : 112/83 mmhg
ill/Obese II/ GCS 15 (E4V6M5)
• Pulse rate : 140 bpm
• Weight: 98 kg
• Temperature : 36,6 °C
• Height: 170 cm
• Respiratory rate : 24 beats/minute
• BodyMass Index : 33,9 kg/m2
(Obese II)
Physical Examination
Head and Neck Examination
• Head : Normocephal, mesocephal
• Eyes : Anemic (-), icteric (-)
• Neck : JVP R+0 cmH2O, no lymphadenopathy and thyroid gland
enlargement
Thorax Examination
• I : Symmetric, there were no abnormality of shape and chest wall
• P : There was no tumor mass, tenderness, and vocal fremitus was not
increased
• P : Sonor in both chest
• A : Vesicular breathe sound, rhonchi (-), wheezing (-)
 Physical Examination
Cardiac Examination :
- I : Ictus cordis not seen
- P : no palpable ictus cordis
- P : Upper : 2nd ICS left parasternalis
Right : 4th ICS right parasternalis
Left : 5th ICS left axillary anterior
- A : Regular S1 S2 heart sound,
murmur absence
Abdomen Examination :
- I : normal movement of
abdominal wall along with
respiration
- P : Mass (-), pain (-)
- P : Tympani (+)
- A : Peristaltic normal
Extremity Examination :
- No wasting and pretibial edema
 Investigation : Electrocardiogram

Supraventrikular rhythm, HR 140 bpm, regular, normoaxis, T inverted V1-V6

Conclusion : Supraventricular tachycardia, Ischemic anterior wall
Post Cardioversion

Sinus rhythm, HR 70 bpm, regular, normoaxis, T inverted V1-V5

Conclusion : Ischemic anterior wall
Investigation : Lab Findings
TEST RESULT NORMAL VALUE TEST RESULT NORMAL VALUE

WBC 6.5 4.00 – 10.0 PT 18.2 10-14

RBC 4.99 4.00 – 6.00 INR 1.83 --

HB 14.6 12.0 - 16.0 APTT 34.8 22.0 - 30.0

MCV 83.8 80.0 – 97.0 SGOT 18 <38

MCH 29.3 26.5 – 33.5 SGPT 31 <41

MCHC 34.9 31.5 – 35.0 UREUM 37 10– 50

PLT 415 150 - 400 CREATININE 0.77 L <1.3 P <1.1

GDS 130 140
NEUT 58.9 52.0 – 75.0
LYMPH 32.7 20.0 – 40.0 NATRIUM 142 136 – 145

MONO 6.9 2.00 – 8.00 KALIUM 4.6 3.5 – 5.1

EO 0.9 1.00 – 3.00 KLORIDA 108 97 - 111

Investigation : Radiology (12/8/2019)
• Cor : Enlargement of cor with CTI:
0.61, flattening cardiac waist, normal
aorta
• Both sinus and diaphragm normal
• Intact bone
• Soft tissue normal
• Conclusion : Cardiomegaly
Investigation : Echocardiogram Report
• Left ventricular systolic function decreases EF 35% (BIPLANE)
• Concentric left ventricular hypertrophy
• Myocardial movements: Segmental hypokinetic
• Mild mitral regurgitation, mild pulmonary regurgitation
• Moderate diastolic dysfunction
Assessment
• Atrial Flutter
• Coronary Artery Disease
• Heart Failure Reduce Ejection Fraction
Treatment
• Cardioversion 50 joule
• Cardioversion premedication
• B-Blocker : Bisoprolol 2,5 mg/24 hours/ oral
• ARB : Candesartan 8 mg/ 24 hours/ oral
• Mineralocorticoid antagonist : Spironolactone 25 mg/ 24 hours/ oral