VIDINI KUSUMA AJI

30101307094

Advisor :
dr.H.M. Saugi Abduh, Sp.PD, KKV, FINASIM
 Name : Mrs. F
 Age : 43 years old
 Sex : woman
 Religion : Moslem
 Job : housewife
 Address : Ronggowarsito 110 L
Tanjungmas RT. 04/10 Semarang Utara
 Medical Record Number : 01.25.01.90
 Room : Baitul Izzah 1
 Entry Date : 14th January 2018
 Date Out : 20 th Januaryr2017
 MAIN PROBLEM
Chest Pain
HISTORY OF PRESENT ILLNESS
Patients came to the emergency room of sultan agung islamic Hospital
with complain of chest pain. Patient feel the chest pain since 1 days ago.
The patient said chest pain like stabbed and pressed. Chest pain appears
suddenly while he activity. Chest pain appeared more than 20 minutes.
The pain radiating to the shoulders and left arm. Patients also complained
that she had difficult to breathe and weakness.
Onset : 1 days ago
Location : Pain at chest radiating to shoulder and left arm.
Chronology : She complained that 1 days ago chest pain while she activity.
Quality : Patients described her chest pain like stabbed an pressed
Quantity : The pain radiating to shoulder and left arm duration >20 minutes
Modifying factors : Patients feels chest pain mostly when she working some activities
Other complaints : Patients also complained that she had difficult to breathe and weakness
HISTORY OF PREVIOUS ILLNESS
›Same symptom / illness (+)
›Hypertension history (+)
›DM history (+)
›Asthma history (-)
›Alergy history (-)
›Cardiac Disease (+)
›Drug allergy (-)
›Smoking history (-)
Family’s history of disease
•Hypertension history (+)
•DM history (-)
•Asthma and alergy history (-)
Sosio – Economic History
•Economic Impression :
enough
•Hospital cost certified by
JKN Non PBI
GENERAL PHYSICAL EXAMINATION GENERAL STATUS

Date : 19 January 2018

BMI (Body Mass
•General : weakness Indeks)
•Awareness : composmentis Weight : 90 kg
Height : 155 cm
•Vital Sign : BMI =
-BP = 160/100 mmHg 37,5
-Pulse = 70 x/minute
-RR = 24 x/minute (OBESITAS CLASS II)
-T = 36,7 ◦ C
• Head : Mesocephal, alopesia (-)
• Eyes : Anemic conjuntiva(-/-), Icteric sclera(-/-)
• Nose : Symmetric, secret (-), Nostril Breath (-)
• Ears : Normal shape, discharge (-/-)
• Mouth : Cyanosis (-), dry lips (-), snoring (-)
• Neck : Trakhea deviation (-), Lymph Hypertropy (-)
• Extremity : Oedem of lower extremity (-), Oedem of upper
extremity (-)
 CHEST EXAMINATION - LUNG
Date : 19 January 2018
EXAMINATION ANTERIOR POSTERIOR

Inspection - Static RR : 20 x/minute RR : 20 x/minute

Thoracal breathing Thoracal breathing
Hyperpigmentasi (-) Hyperpigmentasi (-)
Spider navi (-) Spider navi (-)
Atrofi M. Pectoralis (-) Atrofi M. Pectoralis (-)
Hemithorax D = S Hemithorax D = S
ICS Normal ICS Normal
Diameter AP < LL Diameter AP < LL
Inspection – Dinamic Up and down of Up and down of
hemithoraks D = S hemithoraks D = S
Muscle retraction of Muscle retraction of
breathing (-) breathing (-)
Retraction ICS (-) Retraction ICS (-)
 CHEST EXAMINATION - LUNG
Date : 19 January 2018
EXAMINATION ANTERIOR POSTERIOR

Palpation Palpation pain (-) Palpation pain (-)

Mass (-) Mass (-)
Stemfremitus D = S Stemfremitus D = S

Percution Sonor (+) Sonor (+)

Auscultation Vesiculaar (+) Vesiculaar (+)

Wheezing (-) Wheezing (-)
Ronchi (-) Ronchi (-)
INTERPRETATION Normal Normal
 THORAX - COR
Date : 19 January 2018

INSPECTION

Ictus cordis -

PALPATION

Ictus cordis Palpable at ICS V 2 cm medial from

linea mid clavicula sinistra
thrill -

Pulsus epigastrium +

Pulsus parasternal +

Sternal lift +
 THORAX - COR
Date : 19 January 2018

PERCUTION

Upper borderline ICS II linea sternalis sinistra

Waist ICS III linea parasternalis sinistra

Lower right borderline ICS V linea parasternalis dextra

Lower left borderline ICS IV 2 cm medial from linea mid

clavicula sinistra
 Aorta valve : S1 & S2 standart,
additional sound (-)

AUSCULTATION - COR

Pulmonary valve : S1 &

S2 standart, additional
sound (-)

Pulmonary valve : S1 &

S2 standart, additional
sound (-)

Pulmonary valve : S1 &

S2 standart, additional
sound (-)
› Interpretation examination
thorax cor : Cardiomegali
 ABDOMEN

Date : 19 January 2018

EXAMINATION RESULTS

Inspection Simetrics
Sycatric (-)
Striae (-)
Enlargement of vena (-)
Caput medusa (-)
Spider navi (-)

Auscultation Peristaltic (+)

Aorta abdominal bruit (-), A.
Lienalis, A. Femoralis (-)
 ABDOMEN
Date : 19 January 2018

EXAMINATION RESULTS

Percussion Shifting dullness (-)

Undulation test (-)
Hepar deaf (+)
Liver span dextra 10 cm
Lver span sinistra 6 cm
Troubles space (+)

Palpation Mass (-)

Pain (-)
Hepatomegali (-)
Hepar, kidney and lien are
normal
Splenomagali (-)
Murphy sign (-)
INTERPRETATION NORMAL
 EXTREMITIES
Date : 19 January 2018

EXAMINATION SUPERIOR INFERIOR

OEDEM -/- -/-

Akran dingin -/- -/-

Refleks Patologi -/- -/-

Refleks Fisiologi +/+ +/+

Ikterik -/- -/-

INTERPRETATION NORMAL NORMAL

 › LABORATORY TEST

DATE : 14 January 2018

PEMERIKSAAN HASIL NILAI RUJUKAN SATUAN

HEMATOLOGY

Hemoglobin 11,6 L 11,7-15,5 g/dL

Hematokrit 35,9 33 – 45 %

Leukosit 11,38 H 3.6 – 11 Ribu/uL

Trombosit 371 150 - 440 Ribu/uL

Golongan darah/Rh A / Positif

 › LABORATORY TEST
DATE : 14 January 2018

PEMERIKSAAN HASIL NILAI SATUAN

RUJUKAN
KIMIA

Ureum 25 10 – 50 mg/dl

Creatinin Darah 0,82 0,6-1,1 mg/dl

High Sensitive 313,3 H < 19 ng/L. ng/L

Troponin I
(TNHS)
INTERPRETATI Troponin Meningkat
ON
 › LABORATORY TEST
DATE : 16 January 2018

PEMERIKSAAN HASIL NILAI SATUAN

RUJUKAN
KIMIA

Cholesterol 162 < 200 mg/dl

Trigliserid 122 < 160 mg/dl

HDL Cholesterol 50 34 – 87 mg/dl

Direct
LDL Cholesterol 113 60 – 130 mg/dl
Direct
Uric Acid 5,4 2,6 – 5,7 mg/dl

INTERPRETATI Normal
ON
› ECG
DATE : 14 January 2018 (IGD)

DESCRIPTION:
Rhytm : Sinus
Regularitas : Reguler
Frekuensi : 75 x/menit
Axis : lead 1 = (+) ; AvF = (+)  NAD
Gelombang P : 0,08 s (normal)
Interval PR : 0,20 s (normal)
Komplek QRS : 0,08 s (normal)
Gelombang Q : normal
Segmen ST : normal
Gelombang T : T inverted in lead I, II, aVF, aVL, V1-V6,

Kesan : ischemic anterolateral

 X ray
  X- Foto Thorax AP
 Cor : CTR tidak dapat dinilai.
- Apeks bergeser ke laterocaudal.
 Pulmo :
Corakan bronkovaskular meningkat, disertai blurring
vascular.
- Tampak bercak pada perihiler dan pericardial kanan kiri.
- Diafragma dan sudut Kostofrenicus baik.
- Kesan : Suspek cardiomegali (LV)
- Pulmo (edem pulmo)
› ECHO
Echo Summary
-Dimensi ruang jantung : membesar di LA
-Dinding LV : menebal di IVS dan PW
-Wall Motion : Global Normokinetik
-Katup Jantung : Normal
-Fungsi LV Sistolik Baik EF 58%
-Fungsi RV Sistolik Baik TAPSE 20 mm
-Fungsi LV Diastolik Baik E/A > 1

KESAN:
Global Normokinetik
Fungsi LV + RV Sistolik baik
Fungsi LV Diastolik baik, LVH konsentrik
Dilatasi LA
 Advance Examination :
ANAMESIS: Laboratory Test
Chest pain - Troponin Meningkat
Difficle breathe
Weaknes
ECG
Trponin I meningkat
- Ischemic anterolateral inferior

X- Ray :
-Cardiomegali (Suspek LV)
Physical Examination -Edem Pulmo
-Cardiomegali.
-Pulsus epigastrium + Echo
-Pulsus parasternal + -Dilatasi LA
-Sternal lift + -LVH Konsentrik
-EF 58 %
 HHD

1.Riwayat HT

2
NSTEMI 2.TD 160/100 mmHg
1.Chest Pain (tipical) >20 menit 3.LVH Konsentrik susp. LV
2.Ischemic anterolateral inferior (T

1
inverted I, II, AVF, AVL, V1- V6)
3.Troponin I Increase

4 DM TYPE 2

1.Riwayat DM
2.GDS 302
CHF

2 1.Weakness
2.Difficult to breath
3.Cardiomegali
4.Edem Pulmo
5 OBESITAS CLASS II

1.BMI = 37,5
 Assesment
• Stratifikasi resiko
 Initial Plan of Diagnosis
 TIMI, GRACE, CRUSADE score risk
 Initial Plan of Therapy
• O2 canul 2 lpm
• ISDN 1 x 5 mg sublingual (kalau perlu)
• Clopidogrel 1 x 75 mg for maintenance,
loading dose 1x300 mg (12 months)
• Aspilet 1 x 80 mg (long life) for
maintenance, 1 x 160 mg for loading dose
• Heparin 12 iu/kgBW/hour (for 8 days)
• Bisoprolol 2,5 mg 1x1
o Initial Plan of Monitoring
• Monitoring klinis pasien
• Vital sign
• APTT/PTT
• ECG
o Initial Plan of Education
• Explain to patient about the disease
• Explain to patient about risk
factor
• Explain to the patient to take
medication regulary
1. Assessment
 Etiology : HHD
 Functional : NYHA IV
 Anatomy : LVH
2. Initial Plan of Diagnosis :
BNP , NT Pro BNP
3. Initial Plan of Therapy
Pharmacology
- Captopril 12,5 mg 3x1
- Furosemid 40 mg 3x1
- Bisoprolol 2,5 mg 1x1
4. Initial Plan of Monitoring
Vital sign
5. Initial Plan of Education :
 Bed Rest/Restriction of physical
activity
 Reducing Emotional stress
 Routine consumption drugs
 Avoid smoking
1. Assessment 4. Initial Plan of Monitoring
 Benigna Vital Sign
 Maligna
5. Initial Plan of Education :
• Explain to patients about the condition, and
2. Initial Plan of Diagnosis : complication that may occur
 Funduscopy • Controlling dietary habits
• Reduce salt intake
• Reduce fluid intake
3. Initial Plan of Therapy
a. Non Pharmacology
 Life style change, Diet low salt, Exercise
b. Pharmacology
• Captopril 12,5 mg 3x1
• Amlodipin 5 mg 1 time a day
1. Assessment
Complication

 Akut komplikasi : KAD

 Kronik : Makrovaskular : CAD, PAD, cerebrovaskuler disease : Mikrovaskular : neuropati,
nefropati, retinopati

Status glikemik

2. Initial Plan of Diagnosis :

a. HbA1c, Fasting plasma glucose, 2 hours plasma glucose,GDS
b. Angiografi, ABPI, CT scan cranium, mikroalbuminuria, funduskopi, EMG

3. Initial Plan of Therapy

a. Non Pharmacology
Life style change, Diet low gluocose, Exercise
1. Pharmacology : Insulin Humalog 3 x 6 unit
4. Initial Plan of Monitoring
 Random Blood glucose
 HbA1C

4. Initial Plan of Education :

• Explain to patients about the condition, and complication that may occur
• Controlling dietary habits
• Reduce glucose intake
• Exercise with CRIPE methods
1. Assessment
 -
2. Initial Plan of Diagnosis :
 -
3. Initial Plan of Therapy
 Non Pharmacology : Life style change, Diet high fiber, Excise

4. Initial Plan of Monitoring

Body weight

5. Initial Plan of Education :

• Diet high fiber
• Excercise
 90 x 155-100 x 1
= 4.950/100
 Basal Metabolic Rate (BMR) = 49,5 ( BB ideal )
25 (wanita) x 49,5 +20%(aktivitas
 Overweight : 15-20 kal/body ringan ) - 20% (obesitas) - 5%
(usia )
weight 1237,5 – 61,87
= 1175,63
So, the calori patient :

15 X 90 = 1350-1800 kalori
› Theory – NSTEMI
 UA NSTEMI AMI

Simpto Angineus 20 Berat > 30 mnt

m mnt/>
Sign + + + & > berat

EKG ST ST depresi Hiperakut T

elevasi/depresi menetap > ST elevasi
T: pos tinggi & dlm & lama Q patologis
simetris /neg T : neg
dalam dalam
Marker CKMB ( - ) CKMB positif CKMB ( + )
Tropinin + / - Troponin - / Troponin + /
+ -
 Theori – CHF
 CHF
› Theory – DM TYPE II
 OBAT ANTIHIPERGLIKEMI ORAL

1. Pemacu Sekresi Insulin (Insulin Sulfonilurea (glibenclamid, gliquidone, glimapiride,

Secretagogue) glicazide, glipizide)
Glinid (repaglinide, nateglinide)

2. Peningkat sensitivitas terhdap Metformin

insulin Tiazolidindion (TZD)

3. Penghambat Absoprsi Glukosa di Penghambat alfa glukosida

saluran pencernaan Acarbose

4. Penghambat DPP IV (Dipeptidyl Sitagliptin

Peptidase IV) Linagliptin

5. Penghambat SGLT 2 (Sodium Canagliflozin

Glucose Co-transpor 2) Dapagliflozin