Brief Report

Date : March 10th 2019

Physician in Charge
IV : dr. Emil, dr.Astrid
IIIA (Ward/IW) : dr. Seprian, dr. Anita
IIIB : dr. Imelda, dr. Trika
IIA : dr. Aris
IIB : dr.Ridlo
Consultant on Duty : dr. Dadang Hendrawan SpJP(K)
 SUBJECTIVE

Mr.M/ 62 yo/ID 11430503

Chief complaint : Chest Pain
Patient went to RSSA with referral letter from Sumber Sentosa Hospital

Patient sufferred from chest pain since 10.30 am (3 hours before admission) after he was
running, chest pain was heavy like sensation, radiated to the back, accompanied with cold
sweating more than 20 minutes with VAS 7/10 and didn’t relieve by rest. Chest pain was
getting worsen with VAS 10/10 30 minutes later. At about 11.20 patient came to Sumber
Sentosa Hospital to get first line treatment. He was diagnosed with STEMI and had given ASA 4
tab and CPG 4 tab. Then he went to RSSA by himself. History of chest pain (+) 1 months ago
when patient watching TV, accompanied with cold sweating, duration 5 minutes and relieved
by rest
There was no history of shortness of breath, palpitation (-), syncope (-), leg oedema (-), PND
(-), Orthopnea (-),
Patient retired from civil servent
Past Medical History:
History of hypertension and diabetes mellitus was denied. He is an active smoker 1/2 pax/day

Family History:
History of sudden cardiac death, heart disease were denied
 OBJECTIVE

Physical Examination
GCS E4 V5 M6
Vital signs
BP 136/76 mmHg  80/50 mmHg
HR: 76 bpm reguler
RR: 20 tpm
SpO2 : 100 % on 02 NC 4 lpm

Head/Neck
Anemic conjunctiva -/-, icteric sclera -/-
JVP R+ 2 cm H2O (45 deg)
Thorax
Cor: Ictus cordis invisible, palpable at ICS V MCL sinistra
S1-S2 regular, murmur (-), gallop (-)
Pulmo: symetrical, rh -/- wh -/-
Abdomen : Soefl, BU(+)
Extremities : oedema -/- warm acral +/+ CRT < 2”
ECG at Sumber Sentosa Hospital March 10th 2019 11.20
ECG II at RSSA March 10th 2019 13.35
 3 hour ago
• Male
• Typical chest pain
• 62 yo
VAS 7/10 not 13.50
• Smoker 1 relieved by rest
• Disposed from
packs/day • Got worsen with
VAS 10/10  came Emergency • Called SPV
to Sumber Sentosa Medicine in charge
Risk factors Hospital Departement  agree to
• Loading ASA 4 tab. PPCI
CPG 4 tab 13.35

14.30
• Called back
• Patient was 15.10 Persada • Called
Hospital 
referred to they looked Persada
Persada • Called back for available Hospital 
Hospital room and they looked
Persada
asked to call for
Hospital  available
15.30 referral was 20 minutes
later room and
accepted asked to
14.45 call again
15 minutes
Assessment Planning Diagnosis & Therapy
1. STEMI Anterior Killip IV onset 3 PDx:
hours PPCI
2. Heavy smoker ECG/24 jam
Echo full study

PTx
Bedrest
O2 Nasal canule 4 lpm
Inf NS 0.9% Loading 200 cc  1000cc/24 hours
Loading ASA 4 tab, CPG 4 tab (at Sumber Sentosa
Hospital
ISDN 5 mg sublingual (13.45)
Drip Dobutamin 5 mcg/kgBW/min (14.40)
Bolus heparin 60 IU/Kgbw/Ho  continued drip
heparin 12 IU/KgBW/Ho

Referred to Persada Hospital pro PPCI because

catheterization lab of RSSA still not available yet
 CONDITION IN PERSADA HOSPITAL ER
Subjective : chest pain subsided (VAS 1/10)
Objective :
BP: 131/67 mmHg on Dobutamin 5 mcg/ kgBW/min
HR : 71 bpm
RR: 19 tpm
Tax : 36.5
SpO2 : 99% Room air