Morning Report

Friday, October 11th 2019

Reis
Nirsyad
Doddy
Diza
James
Andika
Abinisa
Okto
No. Identity Diagnosis
1. Mr. SP/ 52 years old ST Elevation Myocardial Infarct extensive
anterior wall onset > 24 hours KILLIP I
2. Mr. RN/ 59 yeard old Unstable Angina Pectoris Moderate Risk
 1st Patient
Name : Mr. SP
Age : 52 years old
Address : Maros
MR : 894155
Date of Admission : 11th Oct 2019
DPJP : dr. ZD

The patient was referred from Salewangang Maros Hospital

with diagnosis STEMI Anteroseptal
 History Taking
A 52 y.o man was admitted with Chest pain
Chest pain was felt since 2 days before reffered to PJT, radiated to the back,
pressed-like sensation, acompanied with diaphoresis and nausea with duration
more than 20 minutes, not relieved by rest or nitrat. History of chest pain (-). No
shortness of breath or history of shortness of breath before.
Coronary Risk Factor:
• History of hypertension (+) since 10 years ago, not taking medicine regularly
• History of DM (-)
• History of smoking (-)
• Known family history of cardiovascular disease (-)

At Salewangan hospital, the patient was given aspilet loading dose 160 mg, loading dose
clopidogrel 300 mg, Nitrokaf retard 2,5 mg oral, ISDN 5 mg
 Physical Examination
• BP: 140/90 mmHg, HR : 110 bpm, regular, RR : 20 tpm, T: 36.4
0C,

• Conjunctiva not anemic, sclera not icteric

• JVP R+2 cmH2O
• Vesicular breath sound, Rales (-), Wheezing (-)
• S1 S2 regular, Murmur (-)
• Abdomen: Peristaltic (+) H/L not palpable
• Warm extremities, extremities edema (-)
 ECG at Maros ER 10/10/2019
17.30

Sinus Rhythm, Heart Rate 100 bpm, axis 30o, P wave 0,08 s, PR Interval 0.16s, QRS duration 0,08 s,
ST segment elevation at I, aVL, V1-4
Conclusion : Sinus Rhythm, HR 100 bpm, normoaxis, acute extensive anterior wall Myocardial Infarction
 ECG at PJT 11/09/2019
17.00

Sinus Rhythm, Heart Rate 110 bpm, axis 30o, P wave 0,08 s, PR Interval 0.16s, QRS duration 0,08 s,
ST segment elevation at I, aVL, V1-4
Conclusion : Sinus Tachicardia, HR 110 bpm, normoaxis, extensive anterior wall myocardial infarct
 Laboratory Findings
(11/10/2019)
WBC 14.6 4-10 x 103/mm3
Diff Count (N/L/M/E/B) 82.8/9.5/7.6/0.0/0.1 %
HGB 15.1 12-16 g/dl
MCV 81 80-97 fL
MCH 29 26.5-33.5 Pg
MCHC 36 31.5-35 gr/dl
PLT 256 150-400 x 103/mm3
HCT 42 37-48 %
PT 10.5 10-14 detik
INR 1.01
APTT 24.8 22.0 – 30.0 detik
SGOT 725 <38 U/L
SGPT 94 <41 U/L
Ureum 20 10-50 mg/dl
Creatinin 0.78 <1.1 mg/dl
RBG 141 <140 gr/dl
Sodium 136 136 – 145 mmol/l
Potassium 3.5 3.5 – 5.1 mmol/l
Chloride 103 97 – 111 mmol/l
Hs Troponin I > 40.000 17-50 Ng/l
Chest X-Ray
11/10/2019
Chest X-Ray PA
• Hazziness at parahilar and
paracardial of both hemithorax
• Cor enlarged with CTI 0.6,
concave cardiac waist, with
grounded apex
• Intact bones
• Dilatation and elongation of
aortae

Conclusion :
Cardiomegaly with sign of
pulmonary congestive
 Echocardiography (11/10/2019)
• Decreased LV Systolic Function, EF 31.2 % (TEICH) 30 % (BIPLANE)
• Cardiac chamber : LV Dilatation
LVEDd : 5.6 cm, LVEDs: 4.77 cm, LA Major : 4,6 cm, LA Minor: 4,4 cm, RA Mayor 3.7 cm, RA Minor 2.7 cm,
RVDB 2.0 cm, Ao 3,4 cm, LA 3,2 cm, LA/Ao 0,9)
• Left Ventricle Hypertrohy: positive concentric (LVMI 133 g/m2, RWT 0.35)
• Myocardial Movement : akinetik basal mid anteror, anterolateral, apicoeptal, aoicosentral, hipokinetic apicoanterior,
apicoseptal
• Normal RV systolic function, TAPSE 2.6 cm
• Cardiac Valves :
– Mitral : MR Mild (MR ERO 0,19, MR Vol 16 ml)
– Aorta : 3 cusps, calcification (-) Good Function and Movement
– Tricuspid : Good Function and Movement
– Pulmonal : Good Function and Movement
• E> 2
• eRAP 8 mmHg
• E/A
Conclusion:
Decreased LV Systolic function EF 30 %(BIPLANE)
LVH Dilatation
Eccentric LVH
Segmental Hypokinetic, Akinetik
MR Mild
Mild diastolic LV dysfunction
 Working Diagnosis
• STEMI Extensive Anterior Wall onset 24 hours KILLIP I
(TIMI score 6; 30 days mortality after MI: 2.2%)
• Elevated Enzyme Transaminase
 Management
• Aspilet 80 mg/ 24 Hours/ oral
• Clopidogrel 75 mg/24 hours/oral
• Ramipril 2,5 mg/24 Hours/Oral
• Fondaparinux 2,5 mg/24 hours/subcutan
• Bisoprolol 2,5 mg/24 hours/oral
• Nitrokaf 2,5 mg/24 hours/oral
• Laxadyn 15 cc/24 hours/oral
• Atorvastatin 40 mg/24 hours/oral
 Plan
• Transfer to CVCU
• Primary PCI strategy
 2nd Patient
Name : Mr. RS
Age : 59 years old
Address : Toraja
MR : 898175
Date of Admission : 12th Oct 2019
DPJP : Prof AA

The patient was referred from Elim Toraja Hospital with

diagnosis APS
 History Taking
A 59 y.o man was admitted with Chest pain
It was felt since 3 days before admission, radiated to the back and to the left arm, pressed-like
sensation, duration more than 20 minutes accompanied with diaphoresis and nausea. The
pain was not aggravated by activity and not relieved by rest or nitrat. History of chest pain (+),
he was admitted at Grestelina Hospital on 2017 diagnosed with coronary occlusion but he did
not take his medicine regularly. No shortness of breath or history of shortness of breath
before.
Coronary Risk Factor:
• History of hypertension (-)
• History of DM (-)
• History of smoking (+) since 20 years ago, 20 pcs daily
• Family history of cardiovascular disease (-)

At referred hospital, the patient was given aspilet loading dose 160 mg, loading dose clopidogrel 300 mg,
Nitrokaf retard 2,5 mg oral, ISDN 5 mg oral. Simvastatin 20 mg, lansoprazole oral
 Physical Examination
• BP: 130/90 mmHg, HR : 80 bpm, regular, RR : 20 tpm, T: 36.5
0C,

• Conjunctiva not anemic, sclera not icteric

• JVP R+1 cmH2O
• Vesicular breath sound, Rales (-), Wheezing (-)
• S1 S2 regular, Murmur (-)
• Abdomen: Peristaltic (+) H/L not palpable
• Warm extremities, extremities edema (-)
 ECG at Toraja Hospital 10/10/2019
17.30

Sinus Rhythm, Heart Rate 62 bpm, axis 30o, P wave 0,08 s, PR Interval 0.16s, QRS duration 0,08 s,
Poor R wave progression, ST depression V5-V6, I, aVL, S at V1 + R at V5 > 35 mm
Conclusion : Sinus Rhythm, HR 62 bpm, normoaxis, ischemia lateral wall, Left Ventricle Hypertrophy
 ECG at PJT 12/10/2019
04.20

Sinus Rhythm, Heart Rate 75 bpm, axis 30o, P wave 0,08 s, PR Interval 0.24s, QRS duration 0,08 s,
Poor R wave progression, ST depression V5-V6, I, aVL, S at V1 + R at V5 > 35 mm
Conclusion : Sinus Rhythm, HR 75 bpm, normoaxis, lateral wall ischemia, 1st degree AV block left ventricular
Hypertrophy
 Laboratory Findings
(12/10/2019)
WBC 9.4 4-10 x 103/mm3
Diff Count (N/L/M/E/B) 76.0/15.8/6.2/1.7/0.3 %
HGB 13.9 12-16 g/dl
MCV 93 80-97 fL
MCH 34 26.5-33.5 Pg
MCHC 36 31.5-35 gr/dl
PLT 211 150-400 x 103/mm3
HCT 38 37-48 %
PT 10.6 10-14 detik
INR 1.02
APTT 25.4 22.0 – 30.0 detik
SGOT 22 <38 U/L
SGPT 28 <41 U/L
Ureum 21 10-50 mg/dl
Creatinin 1.01 <1.1 mg/dl
RBG 121 <140 gr/dl
Sodium 143 136 – 145 mmol/l
Potassium 4.0 3.5 – 5.1 mmol/l
Chloride 108 97 – 111 mmol/l
Hs Troponin I 67.2 -> 64.4 17-50 Ng/l
Chest X-Ray
12/10/2019
Chest X-Ray PA
• Cor enlarged with CTI 0.59,
concave cardiac waist, with
grounded apex
• Intact bones
• Dilatation and elongation of
aortae

Conclusion :
Cardiomegaly
Dilatatio and elongatio aortae
 Echocardiography (12/10/2019)
• Decreased LV Systolic Function, EF 38 % (TEICH) 36 % (BIPLANE)
• Cardiac chamber : LV Dilatation
LVEDd : 6.29 cm, LVEDs: 5.47 cm, LA Major : 5,2 cm, LA Minor: 4,1 cm, RA Mayor 4.7 cm, RA Minor 3.6 cm,
RVDB 2.6 cm, Ao 3,9 cm, LA 3,7 cm, LA/Ao 0,94)
• Left Ventricle Hypertrohy: positive concentric (LVMI 168 g/m2, RWT 0.38)
• Myocardial Movement : akinetik basal mid anteroseptal, hipokinetic basal mid anterior, apicoanterior, apicoseptal
• Normal RV systolic function, TAPSE 1.2 cm
• Cardiac Valves :
– Mitral : Good Function and Movement
– Aorta : 3 cusps, calcification (+) AR Mild (AR PHT 536)
– Tricuspid : Good Function and Movement
– Pulmonal : Good Function and Movement
• E> 2
• eRAP 8 mmHg (IVC ekspirasi 1.7/inspirasi 1,3)
• E/A > 1 (Pseudonormal)

Conclusion:
Decreased LV Systolic function EF 36 %(BIPLANE)
LVH Dilatation
Eccentric LVH
Segmental Hypokinetic, Akinetic
AR Mild
Moderate diastolic LV dysfunction
 Working Diagnosis
• Unstable Angina Pectoris Intermediate Risk
(GRACE score 109, 5% probability of death from admission to 6
months)
 Management
• Aspilet 80 mg/ 24 Hours/ oral
• Clopidogrel 75 mg/24 hours/oral
• Ramipril 2,5 mg/24 Hours/Oral
• Fondaparinux 2,5 mg/24 hours/subcutan
• Atorvastatin 40 mg/24 hours/oral
• Nitrokaf 2,5 mg/24 hours/oral
 Plan
• Transfer to CVCU
• Invasive strategy
• Lipid Profile
THANK YOU