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74 YEARS OLD WOMAN WITH

ANTEROSEPTAL OLD MYOCARD


INFARCTION
Lecturer :
Prof. DR. dr. Moch. Fathoni, Sp.
JP(K), FIHA
By:
By:
Afandi
Afandi Dwi
Dwi Harmoko
Harmoko
Ike
Ike Pramastuti
Pramastuti
Dessy
Dessy Tri
Tri Pratiwi
Pratiwi
Nesaraja
Nesaraja Ramakhrisna
Ramakhrisna

Patient Identity

Name
: Mrs. D
Age
: 74 years old
Gender
: female
Religion
: moslem
Occupation
: housewife
Address
: Grogol-Sukoharjo
Medical Record : 01177525
Hospitalized
: February 10th2013

CHIEF
COMPLAINT

Shortness
of breath

Historyof
ofPresent
Present illness
illness
History
Approximately a week before hospitalized,
patient felt the shortness of breath. It appeared
on activity and decreased by rest. Cold sweating
(+), awakened at night because of breathless
(+), breathless caused by changing position (-),
fainting (-), bloody coughing (-), easily tired (-).
About 3 Months ago patient complained a chest
pain, but she didnt go to the hospital, because
the pain relieved it self. Pain at left shoulder (+),
cough (+) Nausea (-), Vomitting (-)

History of past illness

History
History
History
History
History
History
History

of
of
of
of
of
of
of

heart disease
:
hypertension
:
stroke
: (-)
diabetes mellitus
hospitalization :
Asthma
: (-)
allergy
: (-)

(-)
(-)
: (-)
(-)

EATING BEHAVIOR

2-3 times a day, consumed rice,


vegetables, tahu-tempe, occassionally
eggs ang meat.

LIFE STYLE

No regular sports. Didnt smoke. Didnt


drink alcohol.

SOSIOECONOMIC

She is a housewife with 4 children and


5 grandchildren. Her husband was
dead 7 years ago. She lives with her
son. Her son works as a labour.

PHYSICAL EXAMINATION
General Condition: Compos Mentis,
moderate illness
Vital Signs:
BP = 100/70 mmHg
HR = 90 bpm, reguler, normal intensity
RR = 20 times/minute
Temperature = 36,2C (axillar)
Nutritional status = normoweight

Eyes : Pale conjunctiva (-/-),


Icteric conjunctiva (-/-)
Neck : JVP wasnt increased,
No enlargement of
Lymphnode
Thorax : normochest, symmetrical,
intercostal retractions (-)

Heart :
- Inspection : Ictus cordis wasnt seen
- Palpation : Ictus cordis wast palpable
- Percussion :
1. Upper limit of the right heart: SIC II, linea parasternalis
dextra
2. Bottom right cardiac border: SIC IV, linea parasternalis
dextra
3. Upper left cardiac border: SIC II, linea parasternalis
sinistra
4. Lower left cardiac border: SIC V, 2 cm to the lateral side
of the linea mid clavicula sinistra
Impression: cardiac border wasnt extend
- Auscultation:
1. Heart Rate: 90 x/ min, regular
2. Intensity of the Heart sound I-II are normal, regular,
murmurs (-), Gallop (-)

Lungs :
Front
Inspection
: static and dynamic symmetric
Palpation
: fumbling fremitus for right = left
Percussion
: sonor/ sonor
Auscultation
: Basic vesicular sounds (+/+),
Fine crackles (+/+), rales (+/+), wheezing (-/-)

Back
Inspection
: static and dynamic symmetric
Palpation
: fumbling fremitus for right = left
Percussion
: sonor / sonor
Auscultation: basic vesicular sound (+/+), fine
crackles (+/+) in, rales crackles (+/+) lung fields,
wheezing (-/-)

Abdominal :
- Inspection : abdominal wall = chest wall
- Auscultation : bowel peristaltic (+) normal
- Percussion : tympanic
- Palpation : outgoing, tenderness (-), liver and
spleen not palpable
Back : Kyphosis (-), lordosis (-), scoliosis (-)
Extremity :
- Above : pitting edema (-/-), cold acral (-/-),
wound (-/-), clubbing finger (-/-), spoon nail (-/-)
- Under : pitting edema (-/-), cold acral (-/-),
wound (-/-), clubbing finger (-/-), spoon nail (-/-)

10/2/2013

L
A
B
O
R
A
T
O
R
Y

F
I
N
D
I
N
G

15/2/2013

UNIT

Hb

9,9

g/dl

HCT

32

RBC

3,56

106/l

WBC

9,1

103/l

PLT

299

103 /l

GDS

118

mg/dL

Ureum

53

mg/dL

Creatinin

1,8

mg/dL
130

mmol/L

Kalium

2,8

mmol/L

Chlorida

91

mmol/L

Natrium

Ca Ion

mmol/L

CKMB

ng/l

Troponin

ug/l

L
A
B
O
R
A
T
O
R
Y

10/02/201
3

F
I
N
D
I
N
G

15/2/201
3

UNIT

SGOT

190

u/l

SGPT

91

u/l

Triglyserid

83

mg/dl

Total
cholesterol

116

mg/dl

LDL
Cholesterol

58

mg/dl

E
C
G

Tgl
25/5/2011

E
C
G

E
C
G

E
C
G

Sinus Rhythm, HR 106 bpm


Normoaxis
Poor R waves V1-V4
VES, Multiform

E
C
G

KATZ- WACHTEL PHENOMENON

LVH/ LBBB in precordial lead & LAD


Tall R in all precordial leads & RAD
High/deep amplitude of QRS in V2V4
LVH & P pulmonal in the limb lead

E
C
G

CONCLUSIO
N:
- AF rapid ventricular
response HR 160x/mnt
- Poor R wave progression
- Biventricular enlargement

C
H
E
S
T
XRAY

C
H
E
S
T
XRAY

Simetric
Bronchovascular system is normal
Perihiller haze in both lungs
Costophrenic angle is blunt
CTR >50 %
Calsification of aortic knob

CONCLUSION
Cardiomegaly with aorto
schlerosis
Oedem pulmo
Bilateral efussion of pleura

C
H
E
S
T
XRAY

DIAGNOSIS
Anatomic : anteroseptal
OMI
Functional :
Decompensated cordis
NYHA IV
Etiology : coronary heart
disease
Risk Factors : Age,
Menopause

T
R
E
A
T
M
E
N
T

Bed rest
O2 3lt/mnt
Infus RL 10 dpm
Furosemid Inj 20 mg/8 hours
Ranitidin Inj. 50 mg/12 hours
Spironolakton 25 mg 1-0-0
ISDN 3 x 5 mg
Captopril 3x12,5 mg
Simvastatin 20 mg 0-0-1
Alprazolam 0,5 mg 0-0-1
Aspilet 80 mg 0-1-0
Ambroxol 3x30
Allopurinol 100mg 0-0-1
KSR 3x1

P
L
A
N

Consult pulmonologist for


pleural effusion
Consult Internist for azotemi
and increased transaminase
level

PROGNOSIS
Ad Vitam : dubia ad bonam
Ad Sanam : dubia ad malam
Ad funsionam : dubia ad malam

THANK YOU
YOU
THANK
FOR YOUR
YOUR
FOR
ATTENTION
ATTENTION