Scheduled: April 15th 2021

Case Report

A 59 Years Old Woman with Chest Pain CCS II ec Non ST-Elevation Myocardial
Infarction TIMI 5 ec CAD 3VD, HFpEF FC NYHA II Killip I and Type II Diabetes
Mellitus

Presentan:
dr. Muhammad Kamaluddin Kacaribu
NIM 22041417310002

Moderator :
dr. Rudy Handoyo, Sp.KFR(K)

PHYSICAL MEDICINE AND REHABILITATION

FACULTY OF MEDICINE DIPONEGORO UNIVERSITY
SEMARANG
2021

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I. IDENTITY
Name : Mrs.S
MR Number : C759236
Age : 59 years old
Address : Jl. Ngembel Kidul, Grobogan
Religion : Islam
Education : High school
Occupation : Self-employee
Date of exam : March 17th 2021
Payment : BPJS Non PBI

II. ANAMNESIS (AUTOANAMNESIS)

2.1 Chief complain:
Chest pain

2.2. History of present illness:

The patient has been feeling chest pain since 3 years ago and getting worse since 1
year ago. The pain located in left side of her chest. It was dull with sensation like being
compressed in her chest less than 30 minutes. It was felt especially at doing housework,
walking more 200 meters and climbing stairs but relieved with a rest. Initially, in june 2018,
she felt chest pain in mild intensity when washing clothes. it got worse 3 days later with
developing other symptoms like nausea, anxiety and a cold sweat so that her husband took
her to the emergency room of the hospital in Purwodadi. In the emergency room, she was
diagnosed with heart attack and got ISDN, aspirin and canule oxygen. After that she was
moved to ICU room and hospitalized for 3 days. When going home, she got nitrokaf, ISDN,
aspirin, valsartan, atorvastatin, diltiazem and metformin. She was educated to do activities
according to his ability, control risk factor and see cardiologist and endocrinologist for
controlling routinely, however, she just came to the hospital twice for outpatient. She never
visitted physiatrist to undergo cardiac rehabilitation program. Finally, in the last control, the
doctor suggested that she should undergo surgery and was referred to Kariadi hospital. On
July 2020, she came to Kariadi hospital but the doctor ask her to undergo surgery 1 year later

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and still took all her medicines regularly. Five days ago, she came to Kariadi and was
admitted in Elang room for waiting surgery that will be performed 6 days later.
Currently, she still complained of shortness of breath when either walking more than
200 meters or climbing stairs. She also felt tired more easily when doing housework. There
was neither cough nor fever. She slept well with one pillow and didn’t wake up at night due
to shortness of breath. Related to her chest pain, there was no pain from her neck radiating to
arm and neither numbness nor muscle weakness.
Patient can do all daily activities independently without supervision including
bathing, grooming, feeding, toileting, dressing and doing housework with mild intensity.
Patient had a positive mind and her husband always support her to get better in all treatment
programs.

Current medication consumed:

 Nitrokaf R 2,5mg/12 jam
 ISDN prn
 Aspirin 80mg/24 jam
 Valsartan 160mg/24 jam
 Atorvastatin 20mg/24 jam
 Diltiazem 30mg/12 jam
 Metformin 500mg/24 jam

2.3. History of Past Medical Condition

 Patient has been diagnosed to have type 2 diabetes mellitus since 2005 and
prescribed metformin 500mg/12jam.
 Hypertension since 2001 and taking captopril 12,5mg/12jam

2.4. History of Family Illness

Family history of having heart disease, hypertension, dyslipidemia, stroke and
smoking was denied

2.5. History of Psychosocial and Vocational

 Education: She was graduated from high school

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  Family: Patient is married. Her husband is a farmer. They have 2 sons. The first
one is a 29 years old, married and working at factory. The second one is 21 years
old as a student college. Family relationship is good. She and her husband rarely
have intimate relationship due to worry.
 Living situation: She lives in her own house with her husband and 1 son. The
house has one level of floor with 120m2 of area consisting of 2 bedrooms, 1
living room, 1 kitchen and 2 bathrooms with 1 flush toilet and 1 squat toilet.
 Vocational: She works as a self employee by running small shop located in her
house and also do housework in daily activities. She has income approximately
1,5 million per month whereas her husband has income around 5 million per
month.
 Psychological: There were no history of psychological problem. he could accept
his health condition, had a positive mind and motivation, however he was worried
and anxiety to do activities with moderate to high intensity.
 Spiritual history: patient is a moslem. She used to go to musalla especially for
solat maghrib but now only doing it at home.
 Social activities: She has a good relationship with her community. She
frequently follow ‘pengajian’ in her community .

2.6 History of Habit

 There was no history of smoking or alcohol consumption
 Patient didn’t do sport activity, just walked around area of her house with her
huband each Sunday.

2.7 Functional History

Before illness, she was independent in all daily activities like walking in far
distance (more than 200 meters) and climbing stairs without shortness of breath..

Time Time x
Time Activity Allocation METs Energy cost
(hours)

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04.30 – 05.30 Praying 0.2 1.3 0.26

Cleaning house 0.5 2.3 1.15

Cooking 1.0 2.0 2.0
05.30 – 07.30 Showering 0.5 2.0 1.0
Grooming 0.25 1.5 0.5
Breakfast 0.5 1.5 0.75

(Run the shop)

07.30 – 11.00 Sitting tasks, light effort 2 1.5 3
Standing tasks, moderate effort 0.5 3.0 1.5

Lunch 0.5 0.75

1.5
11.00 - 13.00 Praying 0.5 0.65
1.3
cooking

Sitting tasks, light effort 2 1.5 3

13.00 - 17.00 Standing tasks, moderate effort 0.5 3.0 1.5
Praying 2.5 1.3 0.65
0

Close the shop 0.5 2.3 1.15

17.30 -18.30 Showering 0.5 2.0 1.0
Praying 0.5 1.3 0.65

18.30 - 19.00 Dinner 0.5 1.5 0.75

Watching TV 0.5 1.3 0.65

19.00 - 20.00
Praying 0.5 1.3 0.65

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 20.00 – 21.30 Manage grocery of the shop 2 1.3 1.3

21.30 – 04.30 Sleeping 6.5 1 6.5

Total 24 hours 29.36

Physical Activity Level = 35.45/24 = 1.22

Impression: Sedentary or light activity lifestyle

III. PHYSICAL EXAMINATION

3.1. General Physical Examination

Status of Physical Finding Impression

Conciousness Compos mentis Normal

Vital Sign BP: 130/70mmHg Normal

Pulse: 72x/minute
RR: 20x/minute
Temp: 36,6°C
SpO2: 98% / 98% room air
Borg scale:11-0-0 (walking)
VAS: 4-5 (when having chest pain)

Communication Verbal Normal

Nutritional Status Body weight: 60kg overweight

Body height: 152 cm (WHO Asian-BMI)
BMI: 25,97
Waist circumference: 87cm

Balance - Static sitting balance is good Normal

- Dynamic sitting balance is good
- Static standing balance is good (FRT= 28cm)
- Dynamic standing balance is good (TUG = 11s)

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Posture Standing position:
Anterior:
- Head is in midline
- Symmetrical shoulders
- No pelvic obliquity
- No deformity at knee
Lateral:
- Forward head (+)
- No kyphotic
- No hyperlordotic lumbal
- No genu recurvatum.
Posterior:
- Head is in midline
- Symmetrical shoulders
- No scoliosis
- No pelvic obliquity

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 Gait : Normal Gait

Swing Phase

Right Left

Ankle Terminal swing: Terminal swing:

Adequate ankle dorso flexion Adequate ankle dorso flexion
Pre swing : Toe off (+) Pre swing : toe off (+)

Knee Mid swing: Mid swing

Adequate knee flexion Adequate knee flexion

Hip Adequate hip flexion Adequate hip flexion

Step length Adequate

Stride length Adequate

Stance Phase

Right Left

Double support Adequate based

Single support Appropriate

Ankle Heel strike : (+) Heel strike: (+)

Knee Mid stance : Mid stance :

Adequate knee extension Adequate knee extension

Hip Adequate hip extension Adequate hip extension

Trunk Central

3.2. Internal Status

System Physical Findings Impression

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 Skin: brown-colored, hair loss (-), cold wet skin (-),
Within
normal temperature
Integument normal limit
Nail: yellowish (-), sign of anemic/cyanotic (-), capillary
(Wnl)
refill time less than 2 seconds

Head Mesocephal Wnl

Anemic conjunctiva (-/-), icteric sclera (-/-), pupil

Eyes Wnl
isochors φ 3 mm / 3 mm, light reflexes (+/+)

Septum deviation (-), nasal discharge (-), nasal breathing

Nose Wnl
(-)

Ear Tenderness (-), edema (-) Wnl

Mouth Cyanosis (-), pursed lip breathing (-) Wnl

Deformity (-), mass (-), trachea in the midline and

Neck symmetrical, enlargement of lymph nodes (-), carotid Wnl
pulsation normal, JVP 5+4 cm H2O

Heart :
Inspection: no visible ictus cordis - Heart
Palpation: ictus cordis in the 6th intercostalspace (ICS) 1 border
cm lateral the midclavicula line, lift (-) shifted to
Percussion: latero
 Upper border: the 2nd ICS left parasternal line caudal side
Chest
 Right border: the 5th ICS right sternal line
 Left border: the 6th ICS, 1 cm lateral midclavicula - Abnormal
line sinistra heart sound
Auscultation: (pansystolic
S1-S2 normal and regular, PSM murmur 3/6 apex to murmur)
axilla, gallop (-)

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 Lungs :
Inspection: symmetrical movement during inspiration and
expiration, retraction (-)
Palpation: stem fremitus symmetrical, intercostalis space Decrease
symmetrical chest
Chest expansion: Axillaris – proc.xyphoideus – expansion
inf.thoracal : 1-1,5-1 cm (in standing position)
Percussion : sonor on both lungs
Auscultation : vesicular, ronchi (-/-), wheezing (-/-)

Flexible on palpation, liver/spleen : ascites (-), not

Abdomen
palpable, no mass, no tenderness, bowel sound positive Wnl
normal

Upper extremity:
Edema (-/-), wet/cold (-/-), cyanosis (-/-)
Extremity Lower extremity: Wnl
Edema (-/-), wet/cold (-/-),
cyanosis (-/-)

3.3. Neuromuscular Examination

Status Findings Impression

Consciousness Compos mentis (GCS: E4 M6 V5 = 15) Wnl

Cranial nerves Wnl

Normal
(CN I – XII)

Movement ROM Full Wnl

Motor MMT Wnl

55555 | 55555
55555 | 55555

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Tonus Upper and lower extremities muscles : Normotonus Wnl

Trophy Upper and lower extremities muscles : Normotrophy Wnl

Physiological ++/++ for biceps/triceps Wnl

reflexes ++/++ KPR/ACR

Patological -/ - (Hoffman Trommer) Wnl

reflexes -/- (Babinski)

Clonus Upper extremities: -/- Wnl

Lower extremities: -/-

Sensory Exteroceptive: good Wnl

Proprioceptive: good

Instrument Result Interpretation

Barthel Index 95/100 Independent

HRQoL 32

Hamilton Anxiety Rating Scale 12 Mild anxiety

Count Test 20 Inadequate

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IV. SUPPORTING EXAMINATION
4.1. Rontgen Thorax AP (March 2021)

Impression:
Cardiomegali ( LV )
Pulmo tak tampak kelainan

4.2. Electrocardiogram

March 16th 2021

Impression:
 Sinus rhythm

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  LVH (Left ventricular hypertrophy)
 Widespread ST-T abnormality maybe due to the hypertrophy and or ischemia

4.3. Echocardiography Transthoracal (January 26th 2021)

Impression:
 LVH konsentrik
 Fungsi sistolik LV dan RV baik LVEF
65,8 % (Teichz), 60.2 % (Biplane)
 Disfungsi diastolik LV grade I
 MR mild, TR mild, aortic sclerosis
 Kalsifikasi pada PML
 Kalsifikasi pada RCC, NCC
 RWMA(+) sesuai CAD dengan hipertensi
sebagai salah satu faktor resiko
 RWMA (+)

4.4. Coronary Angiography (July 2nd 2019)

Impression:
-RCA (Right Coronary Artery) : Stenosis
80% di mid, kalsifikasi berat +)
-Left main: Normal, pendek
-LAD (Left Anterior Descending): Stenosis
70% di mid-distal, kalsifikasi berat(+)
-Lcx (Left Circumflex): Stenosis 90% di
proximal, kalsifikasis berat (+)
Conclusion: CAD 3VD dengan kalsifikasi
berat diketiga vesselnya

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4.5. Spirometry (March 2nd 2021):
FVC= 74,28 %
FEV1= 84,46 %
FEV1/FVC= 113 %
Impression: Restrictive Mild Spirometry

4.6. Six Minutes Walking Test (March 2nd 2021)

Pretest Posttest

BP 130/60 mmHg 140/70 mmHg

Pulse 92 x/min 107 x/min

O2 sat 99% 98%

Borg Scale 6-0-0 12-0-0

Walk Distance 365 m, without rest

VO2Max 14,9 ml/kg/min

METs 4,2

4.7. Laboratory Finding

4.7.1. Hematology

Examination Result Normal

Hb 12 g/dl 13-16 g/dl

Ht 43.7 % 40-54 %

Eritrosit 4.56 106/mm3 4.4-5.9 106/mm3

MCH 28.6 pg 27-32 pg

MCV 84.3 fL 76-96 fL

MCHC 35 g/dL 29-36 g/dL

Leukosit 7.320 /mm3 3.600-11.000/mm3

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 Trombosit 278.000/ mm3 150.000-400.000/ mm3

RDW 14.5 % 11.6-14.8 %

MPV 9.58 fL 4-11 fL

4.7.2. Clinic Chemistry (29/2/2021)

Examination Result Normal

Random Glucose 102 mg/dL 80 – 160 mg/dL

SGOT 18 U/L 15 – 34 U/L

SGPT 20 U/L 15 – 60 U/L

CKMB 21 U/L 7 – 25 U/L

Albumin 3.9 g/dL 3.4 – 5.0 g/dL

Electrolit

Natrium 138 mmol/L 136-145 mmol/L

Kalium 4.0 mmol/L 3.5-5.1 mmol/L

Chlorida 102 mmol/L 98-107 mmol/L

V. DIAGNOSIS
5.1. Medical Diagnosis
1. Chest Pain CCS II ec Non-STEMI TIMI 5 ec CAD 3VD
2. HFpEF FC NYHA II KILLIP I e/c Non-STEMI ec CAD 3VD, MR mild, TR mild
3. Type II Diabetes Mellitus

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5.2. Functional Diagnosis (Based on ICF)

ICF Code Description Patient’s Condition

Body Structures

s4101 arteries Coronary artery disease (3VD)

Aortic sclerosis

s41001 Ventricles MCI

LVH
s41008 Structure of heart, other PML kalsifikasi
specified

Body Functions

b410 Heart functions Diastolic Heart failure

b4108 Heart functions, other specified MR mild, TR mild
b4150 Function of arteries Chest pain

b440 Respiration functions Shortness of breath, reduced chest expansion

b455 Exercise tolerance functions Low cardiorespiratory endurance and decresed

muscle fitness

b152 Emotional functions Patient is worried and anxiety about her health

Activities and Participation

Mobility

d455 Moving around (climbing) Difficulty in climbing up and down stairs

d469 Walking and moving Patients can only walk 100 meters without shortness
of breath and tired

Domestic Life

d6400 Washing and drying clothes and Chest pain and shortness of breath when doing
garments housework in moderate intensity

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 d6402 Clining living area Same with above condition

Environmental Factors: -

Personal Factor: 59 years old, woman, having a high motivation for treatment

VI. REHABILITATION PROBLEM

1. Chest pain and shortness of breath when either walking more than 200 meters or doing
house in moderate intensity
2. Shortness of breath when walking more than 200 meters
3. Reduced chest expansion
4. Low cardiorespiratory endurance
5. Worry and anxiety

VII. GOALS
7.1. Short Term Goals (Phase I)
1. Can do effectively cough and use incentive spirometry before surgery
2. No feeling worry and anxiety
3. Maintain muscle endurance and strength, flexibility as well

7.2. Long term goals (Phase II, III)

1.Chest expansion in normal range (2-5)

2. Can walk more than 200m and do housework in moderate intensity without shortness of
breath and chest pain
3. Gradual cardiorespiratory endurance improvement (5-8 Mets)

VIII. Rehabilitation Programs

No. Problem Target Programs

1. Preparing surgery to -Can do effectively cough -Education and exercise of
mantain respiratory - Can do lip pursued effective cough and use of
function breathing incentive spirometry
-Can use incentive -Pursued lip breathing

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2. Risk of deconditioning such
as muscle weakness, low
muscle endurance and
flexibility impairment
3 Worry and anxiety
exercise: 3-5x/hour, inhale
2 seconds, exhale 4 seconds
-Incentive spirometry : as
tolerated, increase
gradually, 5x/day @ 10
repetition
Maintain muscle strength 1. Resistance exercise
and endurance of both F: 3 days/week
upper and lower I: 40-60% of 1RM or Borg
extremities, flexibility RPE <13
limbs and trunk as well T: 8-10 set @ 10-15
repetitions
T: Entree and NK-Table
2. Aerobic/endurance
exercise
I: 40-60% of THR
T: 10 minutes 2 times/day,
twice in a week
T:Walking
3. Flexibility exercise
-Stretching exercise and
AROM exercise
No worry and anxiety 1. Relaxation therapy
2. Education:
a. Education about
the importance
of emotion
management
b. Explain that
patient will be
better after
surgery and
cardiac
rehabilitation
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 program

3. Consult to psychologist
Decreased chest expansion -Chest expansion in -Deep breathing exercise:
normal range (2-5 cm) 3-5x/hour, inhale 2
seconds, exhale 4 seconds
-Incentive spirometry : as
tolerated, increase
gradually, 5x/day @ 10
repetition
4 Low cardiorespiratory Cardiorespiratory -Aerobic exercise
endurance endurance improvement F: 3-5x/week
(Phase II) (gradually from 5 METs I: 40-80% VO2max or <13
to 8 MET) points of Borg Scale
T: 20-60 minutes
T: aerobic exercise
(walking)
-Home program:
a. Maintain an active
lifestyle (independent
ADL) with limitation from
Borg Scale (<13)
b. Sit to Stand Exercise 10
repetition, twice a day with
limitation from Borg Scale
(<13)
3. Education:
a. Education about
cardiorespiratory
endurance
Encourage patient to
improve cardiorespiratory
endurance by doing regular
moderate intensity exercise

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 5. Chest pain and shortness of
breath when walking more
than 200 meters and doing
housework in moderate
intensity
(Phase II)
Can walk more than 200 After CABG where cardiac
meters and do housework vascularitations improve
in moderate intensity well, aerobic exercise can
without chest pain and be done advance, until
shortness of breath phase III due to cardiac that
is able to supply O2
demand adequately

IX. PROGNOSIS
1. Ad vitam is bonam

 TIMI 5: 30-day mortality or Recurrent MI about 26,2 % (moderate risk)

 KILLIP I: mortality rate is found to be 2-3 % (mild risk)

2. Ad sanationam is bonam

Patient has CAD 3VD. Independent risk factor for reinfarction in this patient was the
multivessel disease that expose patient to 1,79 times more risk for reinfarction than single
vessel disease patient. Patient is compliance to medication and blood glucose is controlled.

3. Ad functionam is bonam

Patient 6MWT was 4,2 METs, patient is still able to walk < 200 meters. After CABG,
Cardiac perfusion would be better expectedly so that cardiorespiratory patien can be
improved significantly. Patient is also compliance to medication and patient’s ADL is
independent as well.

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Appendix 1. Barthel Index

21
Appendix 2. HeartQoL

Ny. S, 59 tahun
March 17th 2021)

Terima kasih untuk jawaban anda atas pertanyaan-pertanyaan berikut, sehingga kami
dapat memahami bagaimana dampak masalah jantung anda terhadap diri anda.

Kami ingin mengetahui gangguan yang timbul akibat masalah jantung anda dan bagaimana
perasaan anda DALAM 4 MINGGU TERAKHIR.

Mohon centang pada kotak yang

paling sesuai dengan keadaan
anda
Pertama, dalam 4 minggu terakhir, apakah anda
mengalami kesulitan saat: Tidak Sedikit Sering Sangat
3 2 1 0
1. Berjalan dalam rumah pada permukaan datar? √
2. Berkebun, menyapu, atau membawa belanjaan? √
3. Mendaki bukit, atau menaiki tangga tanpa berhenti? √
4. Berjalan lebih dari 100 meter dengan cepat? √
5. Mengangkat atau memindahkan barang yang berat? √

Lalu, dalam 4 minggu terakhir, apakah anda Mohon centang pada kotak yang
terganggu karena: paling sesuai dengan keadaan
anda
6. Merasa sesak napas? √
7. Secara fisik terbatasi? √
8. Merasa lelah, letih, kurang energi? √
9. Tidak merasa tenang atau bebas dari ketegangan? √
10. Merasa tertekan?
√
11. Merasa putus asa? √
12. Merasa khawatir? √

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13. Terbatasi dalam melakukan olahraga atau latihan
fisik?
14. Bekerja di sekitar rumah atau halaman? √

Terima Kasih

Appendix 3. Hamilton Anxiety Rating Scale

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