Morning Report

Saturday, February 8th 2020

Maya
Lia
Dwi Widya
Jacky
Thotuching
Bambang
Hendra (Interna)
Hadi
Triani
 Patient Resume
No. Patient Identity Diagnosis
1. Mr. S / 67 yo - Non ST Elevation Myocardial Infarction
- Hypertensive Heart Disease
- Type 2 Diabetes Mellitus
2. Mrs. K / 34 yo - Congestive Heart Failure
- Rheumatic Heart Disease
- Severe Mitral Stenosis
- Moderate Aortic Regurgitation
- Moderate Aortic stenosis
- Community Acquired Pneumonia
3. Mrs. C / 71 yo - Non ST Elevation Myocardial Infarction
- Congestive Heart Failure
- Post SVT with pre-existing LBBB
- Community Acquired Pneumonia
- Moderate MR
- Anemia normochromic normocytic
 1st Patient
Name : Mr. S
Age : 67 years
Date of Birth : 02-06-1952
Address : Makassar
MR : 895122
Date of Admission : 8 February 2020
DPJP : Prof. AA
 History Taking
Chief complaint : chest discomfort
Worsened since 1 day before admission, heavy like sensation, not radiated.
Triggered by activity, relieved by rest, diaphoresis (-). Shortness of breath (-).
DOE (-), PND (-), orthopneu (-). Cough (-). Epigastric pain (-) , nausea (-),
vomiting (-). No history of previous shortness of breath. No history of previous
chest pain. No history of previous cardiovascular disease.
• History of hypertension (+) since >20 years, taking amlodipine 5 mg not
regularly
• History of diabetes mellitus (+) since >20 years, taking glimepiride 2 mg
regularly
• History of smoking (-)
• History of cardiovascular disease in family (-)
 Physical Examination
• Compos mentis
• BP : 164/107 mmHg, HR: 114 bpm, regular, RR : 20 tpm, T: 36.50C
• Conjunctiva anemic (-), sclera icteric (-)
• JVP R+1 cmH2O (position 30o)
• Vesicular breath sound, Rales (-), Wheezing (-)
• S1/S2 regular, Murmur (-)
• Extremities : edema (-), warm acral.
 ECG 08/02/2020 23.00
(5/5 mm/mV)

Sinus rhythm, heart rate 88 bpm, regular, axis -27o P wave 0.06s, biphasic P wave lead V1, PR interval 0.12s, QRS
duration 0.08s, pathological Q wave lead III, aVF, T-inverted lead V1-V6, S wave V3 + R wave aVL 40mm
Conclusion : Sinus Rhytm, Heart Rate 83 bpm, normoaxis, left atrial enlargement, old myocardial infarction
inferior, ischemic whole anterior wall, left ventricular hypertrophy
 Laboratory Findings (08/02/2020)
WBC 10.4 4-10 x 103/mm3
Diff Count (N/L/M/E/B) 67.3/21.8/9.0/1.3/0.6 %
HGB 13.9 12-16 g/dl
MCV 81 80-97 fL
MCH 28 26.5-33.5 Pg
MCHC 34 31.5-35 gr/dl
PLT 208 150-400 x 103/mm3
HCT 41 37-48 %
PT 12.1 10-14 detik
INR 1.18
APTT 30.1 22.0 – 30.0 detik
SGOT 32 <38 U/L
SGPT 11 <41 U/L
Ureum 33 10-50 mg/dl
Creatinin 1.12 eGFR 67.6 <1.1 mg/dl
ml.min/1.73m2
RBG 209 <140 gr/dl
Natrium 139 136 – 145 mmol/l
Kalium 4.0 3.5 – 5.1 mmol/l
Chloride 106 97 – 111 mmol/l
HsTroponin I 92.4 17-50
Chest X-Ray (08/02/2020)

- Normal vascular markings both

lungs
- Cor : Enlarged CTI = 0.64,
straightened cardiac waist, apex
grounded
- Aorta dilated, calcification (-)
- Intact bones
- Normal soft tissue

Conclusion:
Cardiomegaly
Dilatation of aortae
 Echocardiography (08/02/2020)
1. Heart valves:
• Mitral: MR mild (MR ERO 0,1 cm2, MR RV 8 ml)
• Aorta: 3 cuspis, calcification negative, AR mild, AR PHT 718 ms
• Tricuspid : normal movement and function
• Pulmonal : PR Mild (PR PHT 987 ms, Jet < 1/3 RVOT)

2. Dimension of heart chambers :

• LA : LA major 6,3 cm, LA minor 5,1 cm, LAVI 40 ml/m2
• LV : LVEDd 5,9 cm, LVEDs 5,1 cm
• RA : RA major 4.9 cm, RA minor 4,2 cm
• RV : RVDB 2,6 cm
• Aorta : Ao 3,0 cm, LA 3,4 cm, LA/Ao 1,14

3. Decreased left ventricular systolic function, Ejection Fraction 29 % (TEICH), 30 % (Biplane)

Normal right ventricular systolic function, TAPSE 1,8 cm

4. Left Ventricular Hypertrophy : eccentric positive (LVMI 122 g/m2, RWT 0.3)
5. Myocardial Movement : Akinetic basal mid anteroseptal, anterior, apicoanterior, apicoseptal. Other segmens are hypokinetic.
6. eRAP : 8 mmHg (IVC expiration 1,9 cm, inspiration 1,5 cm)
7. E/A > 2

Conclusion :
• Decreased LV systolic function, EF 30% (BIPLANE)
• LA and LV Dilatation
• MR Mild, PR Mild, AR Mild
• Eccentric LVH
• Segmental akinetic and hypokinetic
• 3rd grade left ventricular diastolic dysfunction
 Working Diagnosis
• Non ST Elevasi Myocardial Infarction High Risk
TIMI Score: 3 (13% risk at 14 days of: all-cause mortality, new or recurrent MI, or
severe recurrent ischemia requiring urgent revascularization), GRACE Score 102
points (4% probability of death from admission to 6 months)

• Hypertensive Heart Disease

• Diabetes Mellitus Type 2
 Management
- NaCl 0,9% 500cc/24 hours/intravenous
- Aspilet loading dose 160 mg/oral, maintenance aspilet
80 mg/24 hours/oral
- Clopidogrel loading dose 300 mg/oral, maintenance
clopidogrel 75mg/24hours/oral
- Fondaparinux 2,5 mg/24 hours/subcutaneous
- ISDN 10 mg/8hours/oral
- Ramipril 2,5 mg/ 24 hours/oral
- Bisoprolol 1,25 mg/24 hours/oral
- Atorvastatin 40 mg/24 hours/oral
 Plan
- Early invasive strategy
- Transfer to CVCU
- Profil lipid
- Consult Endocrine Metabolic Subdivision
 Consult Result
Endocrine Metabolic Division
A/ - Diabetes Mellitus Type 2 non obese

Th/ - Diet DM 1700 kkal

- Glimepiride 2 mg / 24 hours / oral  postponed

Plan : Check FBG, HbA1C

 2nd Patient
Name : Mrs. K
Age : 34 years
Date of Birth : 09-05-1985
Address : Maros
MR : 879656
Date of Admission : 9 February 2020
DPJP : dr. ZD
 History Taking
Chief complaint : shortness of breath
Worsened since 2 hours before admission, DOE (+), PND (+), orthopneu (+).
There no history of Chest pain, There was no palpitations. Epigastric pain (-) ,
nausea (-), vomiting (-). There was a cough with white sputum since 2 days
before, no fever. History of previous shortness of breath (+), intermittent since
10 years ago, admitted with heart valve disease (+), there was no history
cyanosis when child, taking regular medication: furosemide 40mg.
• History of hypertension (-)
• History of diabetes mellitus (-)
• There was no family history with same complaint
 Physical Examination
• Compos mentis
• BP : 118/69 mmHg, HR: 100 bpm, regular, RR : 28 tpm, T: 36.50C
• Conjunctiva anemic (-), sclera icteric (-)
• JVP R+3 cmH2O (position 30o)
• Vesicular breath sound, Rales basal bilateral, Wheezing (-)
• S1/S2 regular, diastolic murmur grade III/IV apex and RUSB
• Extremities : edema (-), warm acral.
 ECG (09/02/2020)

Sinus rhythm, heart rate 100 bpm, regular, axis 107o P wave amplitudo 3mm, P wave duration 0,12s, biphasic P
wave lead V1, PR interval 0.20s, QRS duration 0.08s, pathological Q wave lead I, aVL.
Conclusion : Sinus Rhytm, Heart Rate 100 bpm, RAD, LAE, RAE
GAK USAH DIBACA OMI NYA
 Laboratory Findings (09/02/2020)
WBC 21.4 4-10 x 103/mm3
Diff Count (N/L/M/E/B) 88.2/7.9/3.0/0.6/0.3 %
HGB 13.5 12-16 g/dl
MCV 81 80-97 fL
MCH 28 26.5-33.5 Pg
MCHC 34 31.5-35 gr/dl
PLT 218 150-400 x 103/mm3
HCT 39 37-48 %
PT 10.7 10-14 detik
INR 1.03
APTT 24.9 22.0 – 30.0 detik
SGOT 26 <38 U/L
SGPT 15 <41 U/L
Ureum 26 10-50 mg/dl
Creatinin 0.65 eGFR 115.8 <1.1 mg/dl
RBG 133 <140 gr/dl
Natrium 138 136 – 145 mmol/l
Kalium 3.7 3.5 – 5.1 mmol/l
Chloride 105 97 – 111 mmol/l
Chest X-Ray (08/02/2020)

- Haziness of parahillar and

paracardial of both lungs
- Cor : Enlarged CTI = 0.64, conus
pulmonalis bulging, aortya
normal
- Blunted left costophrenicus
- Intact bones
- Normal soft tissue

Conclusion:
Cardiomegaly with sign of mitral
heart disease
Pulmonary congestion
Left pleural effusion
Bilateral pneumonia
 Echocardiography (09/02/2020)
• Heart valves:
• Mitral: MS severe (MVA Planimetry 0,6 cm, mean PG 14 mmhg, Mean PHT 225 ms, wilkin score 2-2-2-1)
• Aorta: 3 cuspis, calcification negative, AR moderate (AR PHT 466 ms), AS moderate (AVvmax 3,65 m/s, AV mean PG 35,9
mmhg, SVi 17.74, AVA Planimetry 1,1 cm 2)
• Tricuspid : normal movement and function
• Pulmonal : PR trivial
2. Dimension of heart chambers :
• LA : LA major 7,1 cm, LA minor 5,6 cm, LAVI 63,85 ml/m 2
• LV : LVEDd 4,6 cm, LVEDs 2,9 cm
• RA : RA major 5,0 cm, RA minor 2,6 cm
• RV : RVDB 2,7 cm
• Aorta : Ao 2,6 cm, LA 4,5 cm, LA/Ao 1,73
3. Normal left ventricular systolic function, Ejection Fraction 66 % (TEICH), 64 % (Biplane)
Normal right ventricular systolic function, TAPSE 1,8 cm
4. Left Ventricular Hypertrophy : concentric positive (LVMI 118 g/m2, RWT 0,47)
5. Myocardial Movement : Global normokinetic
6. eRAP : 3 mmHg (IVC expiration 1,1 cm, inspiration 0,3 cm)
7. E/A > 1 , E’ Med : 0,03 m/s, E’Lat : 0,06 m/s
8. LVSV: 26,1 , LVSI : 17,44 ( BSA : 1,5)

Conclusion :
• Normal LV systolic function, EF 64% (BIPLANE)
• LA-RA-RV Dilatation
• MS Severe
• AR Moderate, AS Moderate
• Concentric LVH
 Working Diagnosis
• Congestive Heart Failure NYHA II
• Rheumatic Heart Disease
• Severe Mitral Stenosis
• Moderate Aortic Regurgitation
• Moderate aortic stenosis
• Community Acquired Pneumonia CURB 65
score 0
 Management
- Furosemide 40 mg/bolus intravenous
- Furosemide 10mg/hour/syringe pump
- Warfarin 2mg/24 hours/oral
- N-acetylsistein 200mg/8 hours/oral
- Ceftriaxone 2gr/24 hours/intravenous
 Plan
- Transfer to ward
- Transesophageal echocardiography
- Consult Pulmonology Division
 3rd Patient
Name : Mrs. C
Age : 71 years
Date of Birth : 02-04-1948
Address : Makassar
MR : 473389
Date of Admission : 9 February 2020
DPJP : dr. ZD

Referred from RSUD Kota Makassar with diagnosis VT with pulse dd/ SVT with pre-
existing LBBB, ADHF, ACS
 History Taking
Chief complaint : shortness of breath
Worsened since 6 hours before admission to PJT. DOE (+), PND (+), orthopneu
(+). Chest pain (+), pressed like sensation, duration 10 minutes, not radiated.
Accompanied with nausea (+), no diaphoresis and vomiting. Palpitation (-), there
was palpitation at RS Daya, dizziness (-), syncope (-). Productive cough (+) since 2
weeks ago, white sputum, no blood, no fever.
History of previous shortness of breath (+), intermittent since 10 years ago,
taking routine medication, known cardiovascular disease. No history of previous
chest pain. Angiography was recommended but patient refused.
• History of hypertension (+) since >20 years, taking amlodipine 5 mg regularly
• History of diabetes mellitus (-)
• History of medication from cardiologist : furosemide 40 mg, nitrokaf R 2.5 mg,
isosorbid dinitrat 5 mg, candesartan 16 mg, atorvastatin 20 mg.
 Physical Examination
• Compos mentis
• BP : 130/70 mmHg, HR: 83 bpm, regular, RR : 20 tpm, T: 36.80C
• Conjunctiva anemic (-), sclera icteric (-)
• JVP R+1 cmH2O (position 30o)
• Vesicular breath sound, Rales basal bilateral, crackles bilateral,
Wheezing (-)
• S1/S2 regular, systolic murmur grade III/VI apex cordis
• Extremities : edema (-), warm acral.
 ECG at RSUD Kota Makassar
09/02/2020 00.00

Wide QRS complex takikardi, Supraventricular rhythm, heart rate 166bpm, reguler, axis 7o, , absence P wave. QRS
duration 0.26s, R to nadir S waves 60s, no initial R at aVR
Conclusion : SVT with pre-existing LBBB dd SVT with aberrant conduction dd SVT with pre-excitation, LVH
 ECG at RSUD Kota Makassar
09/02/2020 03.00 (post digoxin 0.5mg bolus iv)

Sinus rhythm, heart rate 75 bpm, axis 7o,, P wave 0.04s, PR interval 0.2s, QRS duration 0.14s, M shaped QRS
complex lead I, aVL, V5, V6. rS complex lead V1
Conclusion : Sinus rhythm, heart rate 75 bpm, normoaxis, complete LBBB, LVH
 ECG at PJT
09/02/2020 04.00 (5mm/mV)

Sinus rhythm, heart rate 83 bpm, axis 7o,, P wave 0.04s, PR interval 0.2s, QRS duration 0.14s, M shaped QRS
complex lead I, aVL, V5, V6. rS complex lead V1
Conclusion : Sinus rhythm, heart rate 83 bpm, normoaxis, complete LBBB, LVH
 Laboratory Findings (09/02/2020)
WBC 21.4 4-10 x 103/mm3
Diff Count (N/L/M/E/B) 90.9/3.8/4.4/0.7/0.2 %
HGB 10.4 12-16 g/dl
MCV 82 80-97 fL
MCH 27 26.5-33.5 Pg
MCHC 33 31.5-35 gr/dl
PLT 247 150-400 x 103/mm3
HCT 32 37-48 %
PT 11.7 10-14 detik
INR 1.13
APTT 29.3 22.0 – 30.0 detik
SGOT 56 <38 U/L
SGPT 25 <41 U/L
Ureum 25 10-50 mg/dl
Creatinin 0.81 <1.1 mg/dl
RBG 143 <140 gr/dl
Natrium 141 136 – 145 mmol/l
Kalium 3.5 3.5 – 5.1 mmol/l
Chloride 106 97 – 111 mmol/l
HsTroponin I 183.4 17-50
Chest X-Ray (09/02/2020)

- Infiltrat patches in mid area

both lungs with fibrotic lines
- Cor : Enlarged CTI = 0.65, aorta
calcification (+)
- Blunted right costophrenicus
angle
- Curvatura scoliosis thoracalis
- Normal soft tissue

Conclusion:
Pneumonia bilateral suspect
specific
Pleural effusion dextra minimal
Cardiomegaly with athreosclerosis
aortae
 Echocardiography (09/02/2020)
1. Heart valves:
• Mitral: MR moderate (MR ERO 0,2 cm 2, MR RV 22 ml)
• Aorta: 3 cuspis, calcification negative, AR mild (AR PHT 662 ms)
• Tricuspid : TR trivial
• Pulmonal : Normal function and movement
2. Dimension of heart chambers :
• LA : LA major 6,3 cm, LA minor 3,9 cm
• LV : LVEDd 6,1 cm, LVEDs 5,1 cm
• RA : RA major 4,0 cm, RA minor 3,6 cm
• RV : RVDB 2,3 cm
• Aorta : Ao 2,9 cm, LA 4,0 cm, LA/Ao 1,38
3. Decreased left ventricular systolic function, Ejection Fraction 32 % (TEICH), 31 % (Biplane)
4. Normal right ventricular systolic function, TAPSE 2,2 cm
5. Left Ventricular Hypertrophy : eccentric positive (LVMI 192 g/m2, RWT 0,39)
6. Myocardial Movement : akinetic mild anteroseptal, mid anterior, apicoanterior, apicoseptal, other segments hypokinetic
7. eRAP : 8 mmHg (IVC expiration 1,1 cm, inspiration 0,7 cm)
8. E/A < 1 , E’ Med : 0,03 m/s, E’Lat : 0,08 m/s, E/E’: 15,99

Conclusion
• Moderately abnormal LV systolic function, EF 31% (BIPLANE)
• MR moderate
• LA and LV dilatation
• Akinetic and hypokinetic segmental
• Eccentric LVH
• 2nd Grade LV Diastolic dysfunction
 Working Diagnosis
• Non ST Elevasi Myocardial Infarction high risk
(TIMI Score: 3 (13% risk at 14 days of: all-cause mortality, new or recurrent MI, or
severe recurrent ischemia requiring urgent revascularization), GRACE Score 129
points (10% probability of death from admission to 6 months)

• Congestive Heart Failure NYHA III

• Moderate mitral regurgitation
• Post SVT with pre-existing LBBB
• Community Acquired Pneumonia CURB 65
score 1
• Anemia normochromic normocytic
 Management
- NaCl 0,9% 500cc/24 hours/intravenous
- Aspilet loading dose 160 mg/oral, maintenance aspilet 80
mg/24 hours/oral
- Clopidogrel loading dose 300 mg/oral, maintenance clopidogrel
75mg/24hours/oral
- Fondaparinux 2,5 mg/24 hours/subcutaneous
- Isosorbid dinitrate 1mg/hour/syringe pump
- Furosemide 40 mg/12 hours/intravena
- Candesartan 16 mg/24 hours/oral
- Atorvastatin 40 mg/24 hours/oral
- Spironolactone 25mg/24hours/oral
- Ceftriaxone 2 gr/24 hours/intravenous
- N-ace 200 mg/8 hours/oral
- Paracetamol 1 gr/intravenous if fever
 Plan
- Early invasive strategy
- Transfer to CVCU
- Profil lipid
- Consult Pulmonology Division
 Consult Result
Pulmonology Division
A/ - Pneumonia in elderly CURB 65 Score 1

Th/ - Ceftriaxone 2 gr / 24 hours / intravenous

- N-ace 200 mg / 8 hours / oral

Plan : Check Sputum BTA 2x

Thank You