PASIEN 2

Nama : Tn. M Syamsul

Umur : 25 tahun
BB/TB : 70kg/165cm
Alamat : Malang
Pembiayaan : BPJS kelas 3
MR ID : 11508590
Summary Data Base
Male/25 Y.o/ Admission 5th May 2021
Chief of complaint : Shortness Of breath
The patient was a referral from a private hospital with complaints of severe
shortness of breath since 1 week of before admission. Shortness of breath
occurred since 3 months ago worsened with strenuous activity and improved
with rest, but since 1 week ago, shortness of breath appeared at rest. Cough,
fever, swollen feet are denied
5 hours of before admission the patient complained of chest pain in the middle
of the chest VAS 4/10 duration of 10 minutes, not accompanied by propagation,
cold sweats, nausea, vomiting, or changes in position
History Past Ilness
•3 months ago, the patient had a history of hospitalization due to shortness of
breath, diagnosed as a swollen heart and bronchitis, after returning home, the
complaints decreased but had not completely disappeared.
•6 months ago the patient complained of being easily tired and unable to carry
out activities as usual, but the patient did not seek medical treatment, only took
herbal medicines.
•History of chest pain, palpitations, syncope and leg swelling is denied
Risk factor : History of smoking for 10 years, 2 packs / day, has stopped since 6
months ago. History of HT, DM, CKD, dyslipidaemia, cancer, surgery, stroke
denied
Social history The patient is a wood craftsman, but has not worked since 6
months ago
Covid19 Screening The patient denied any complaints of cough, fever, anosmia,
dysgeusia or Gi tract complaints. The patient has never travelled or been in
contact with a Covid-19 patient
 Physical Examination
General appearance look moderately ill Thorax :
BW: 70 kg, Height 165 cm Cor: ictus cordis palpable ICS V MCL sin, S1 –
BMI: 25.7 kg/m2 (Overweight) S2 regular murmur (-), gallop (-)
GCS E4V5M6 Pulmo:
BP : 144/80 mmHg ves / ves rh -/- wh -/-
HR : 138-140 ves / ves -/- -/-
RR : 20 tpm
Temp : 36.9°C ves / ves -/- -/-
SpO2 : 78-82% on NRBM 15 lpm
Abdomen : flat, soefl, bowel sound N
Extremities : leg swelling -|- warm acral +|+,
Head and Neck :
CRT < 2 sec
Conj. anemis -|-; Icteric sclera -|- ,
pupil isokor +/+, light reflex +/+
JVP R+ 0 cmH2O
 ECG at ICVCU 6/5/2021

Sinus tachycardia, HR 115 x/ minutes, FA normoaxis, HA normoaxis , P pulmonal, PR int 0.15”, QRS duration 0.12”, R/S>1 in lead V1, S
persiten in V6, Strain pattern in V1-V6. Conclusion : RAE, RVH, LVH
CXR at Primary Husada (3-05-2021) AP position, symmetrical, enough inspiration, high
KV
Soft tissue: normal
Bone : Costae R/L normal; ICS R/L normal
Trachea: in the midle
ICS : normal
Cor: Site: normal
Size: CTR 60%
Cardiac waist (-)
Apex : embedded
Costophrenic angles:
R : sharp, L : sharp
Pulmo : bronchovascular pattern was increased,
inverted coma sign (+), inflitrat (-), fibrosis (-)
Aorta: sclerosis (-), elongation (-), dilatation (-)

Conclusion:
Cardiomegaly
Susp Pulmonary Hypertension
CXR at ER RSSA (5-05-2021)
AP position, symmetrical, enough inspiration, high KV
Soft tissue: normal
Bone : Costae R/L normal; ICS R/L normal
Trachea: in the midle
ICS : normal
Cor: Site: normal
Size: CTR 60%
Cardiac waist (-)
Apex : embedded
Costophrenic angles:
R : sharp, L : sharp
Pulmo : bronchovascular pattern was
increased,inverted coma sign (+), inflitrat (-), fibrosis
(-)
Aorta: sclerosis (-), elongation (-), dilatation (-)

Conclusion:
Cardiomegaly
Susp Pulmonary Hypertension
ECHOCARDIOGRAPHY RSSA
05/05/2021
KESIMPULAN :
1. RA, RV, PA dilatasi
2. Fungsi sistolik LV normal (EF 71%)
3. Fungsi sistolik RV menurun
4. AR mild, TR mild dengan PH high
probability
5. Tampak thrombus pada MPA perluasan ke
LPA dan RPA sesuai gambaran pulmonary
embolism
6. Kesimpulan : acute ongoing chronic
Pulmonary Embolism
Hasil CTPA
Terdapat filling defek yg menyokong gambaran pulmonary emboly:
Truncus pulmonalis dg obstruksi ringan 33%
Arteri pulmonalis kanan dg obstruksi ringan 46%
◦ Arteri lobaris superior kanan dengan obstruksi berat sebesar 88%
◦ Arteri segmentalis apical dengan obstruksi total
◦ Arteri segmentalis posterior kanan dengan obstruksi total

arteri lobaris media kanan dg obstruksi sedang sebesar 64%

◦ Arteri segmentalis medial kanan dengan obstruksi total

arteri pulmonalis kiri dengan obstruksi sedang sebesar 53%

Arteri lobaris superior kiri dengan obstruksi ringan sebesar 42%
Arteri segmentalis anterior kiri dengan obstruksi sebesar 91%
Arteri lobaris inferior kiri dengan obstruksi sebesar ringan 26%
Arteri segmentalis laterobasalis kiri dengan obstruksi sedang sebesar 50%
konsolidasi paru bilateral, ground glass opacity pada paru kiri menyokong gambaran infarct paru kiri dd infeksi
supravalvular gerbode type defect
Hasil DUS 05 Mei 2021
Terdapat gangguan aliran dari CFA hingga distal dgn gambaran monofasik
Tidak ditemukan DVT maupun CVI pada kedua tungkai
 Laboratory Finding at RSSA
Parameter 5/05/2021 08/05/2021 Normal Value
Hb 20 18.3 13,4 – 17,7 g/dL

Leukocytes 12.800 12.280 4300-10300/µL

Hematocrit 57.9 52.2 40 – 47 %

Thrombocytes 157.000 191.000 142.000-424.000/µL

MCV 86.1 84.6 80 – 93 fL

MCH 29.6 29.7 27 – 31 pg

MCHC 34.7 35.10 32 – 36 g/dL

RDW

Differential 0.2/0.2/67.2/23.3/9.1 0.1/0.2/0/86.1/8.1/5.5 0-4/0-1/51-67/25-33/2-5 %

count
NLR 2.8
 Chemical Examination
Parameter 5/5/21 6/5/21 15/05/21 Normal Value
RBS 104 78 <200 mg /dl
SGOT 24 0 – 40 U/L
SGPT 24 0 – 41 U/L
Albumin 3.5 3,5 – 5,5 g/dL
Ureum 49.6 46.9 18.0 16,6 – 48,5 mg/dL
Creatinine 2.16 1.51 1.39 <1,2mg/dL
eGFR 41.4 63,277 41.4
ml/min/1,73 ml/min/1,7 ml/min/1,73
m2 3 m2 m2
 Parameter 5/5/21 6/5//21 Normal Value
Troponin I 0.9 0.9 <1.0 ug/L

CKMB 28 32 7-25 U/L

CRP 3.2 < 0.3mg/dL

Procalcitonin 0.45 0.59 < 0.5 ng/mL

low risk
> 2 high risk
Nt Pro BNP 3008 < 85,8 pg/mL

Kolesterol Total 100 < 200 mg/dL

Trigleseride 82 < 150 mg/dL

Kolesterol HDL 46 > 50 mg/dL

Kolesterol LDL 46 < 100 mg/dL

 Parameter 5/5/2021 15/05/2021 Normal Value
Sodium (Na) 133 138 136 – 145 mmol/L
Potassium (K) 3.58 3.42 3,5 – 5,0 mmol/L
Chloride (Cl) 97 105 98 – 106 mmol/L
Uric Acid 10,3 3,4-7,0 mg/dL

Parameter 5/5/2021 Normal Value

PPT 12.7 9.4-11.3 msec
APTT 32 24.6-30.6 msec
INR 1.24 <1.5
CONCLUSION NORMAL
D-Dimer 3.7 ≤ 0.5
Fibrinogen 389 154.3-397.9 mg/dL
 Blood Gas Analysis at RSSA
Date: 5/5/2021 on NRBM 10 lpm
Parameter Result Normal Value
pH 7.44 7.35 – 7.45
pCO2 27.2 mmHg 35 - 45
pO2 48.4 mmHg 80 - 100
HCO3 18.4 mmol/L 21 - 28
BE -6.0 mmol/L -3 - +3
SaO2 86.2 % >95
Alkalosis Respiratory Compensated by Asidosis Metabolic
Hypoxemia dd Mixed Vein
Date :07/05/2021
Parameter Result Normal Value
pH 7.48 7.35 – 7.45

pCO2 20.4 mmHg 35 - 45

pO2 36.6 mmHg 80 – 100

HCO3 15.2 mmol/L 21 – 28

BE -8.5 mmol/L -3 - +3

SaO2 75.1 % >95

Alkalosis Respiratory Uncompensated dd Mixed Vein

 Laboratory Finding at RSSA
Imunoserology
Parameter 07/05/2021 Normal Value
Anti Cardolipin IgM 1.70 Normal <7 MPL U/mL
Elevated >7 MPL U/mL

Anti Cardolipin IgG 10.60 Normal <10 MPL U/mL

Elevated >10 MPL U/mL

ANA Test 0.60 Negatif <1

Positif >1.2

Anti dS-DNA Total 26.6 <25

 Timeline
05/05/2021 07/05/2021 09/05/2021
• Pasien rujukan ke • Sesak (+) demam • Konferensi Bedah
RSSA (+) Jantung
• Sesak (+) • GCS : 456 • Perbaikan kondisi
• BP : 144/80 • BP : 149/98 klinis dan problem
mmHg • HR : 113 infeksi
• HR : 138-140 • SpO2 : 80% on • Inj Ceftiraxon 2x1g
• RR : 20 tpm NRBM 15 lpm • Inj Levofloxacin
• Temp : 36.9°C • Tax : 37.9 1x750mg
• SpO2 : 78-82% • Thrombolysis • Konferensi
on NRBM 15 lpm selanjutnya untuk
• Dx : CTEPH persiapan operasi
Timeline
10-15/05/2021 17/05/2021
• Klinis membaik, problem • Pasien Kontrol Poli
infeksi teratasi, Sesak • Sesak (-)
berkurang • TD : 134/101 mmHg
• TD : 140/90; HR : 95x/m • HR : 102x/m
• Target SpO2 : 80% dengan • RR : 20x/m
Room Air tercapai • Temp : 36.9°C
• Inj Lovenox 2x60mg 
• SpO2 : 84% room air 
Xarelto 2x15mg
• Pasien KRS 90% NK 3 lpm
Revised GENEVA SCORE
The IMPROVE bleeding risk assessment tool

SCORE
4.5
 ASSESSMENT
CTEPH dd acute PE post thrombolysis (revised Geneva 5, sPESI 2, intermediate high
risk)
RHF stg C fc III dt PH
Claudication intermittent extremity inferior bilateral
Pneumonia CAP (resolved)
Secondary polycythemia dt chronic hypoxemia dd hypovolemia
AKI stg I (resolved)
Hypercoagulable state (D-dimer 3.8, improve bleeding 5)
 PEMERIKSAAN FISIK RAWAT JALAN
KU Baik, CM Thorax :
BB: 70 kg, TB 165 cm Cor: ictus cordis palpable ICS V MCL sin, S1 –
IMT: 25.7 kg/m2 (Overweight) S2 regular murmur (-), gallop (-)
GCS E4V5M6 Pulmo:
TD : 134/101 mmHg ves / ves rh -/- wh -/-
HR : 102x/m
RR : 20x/m ves / ves -/- -/-
Temp : 36.9°C ves / ves -/- -/-
SpO2 : 84% room air  90% NK 3 lpm
Abdomen : flat, soefl, bowel sound N
Kepala dan Leher :
Konj anemis -|-; Sklera Ikterik -|- , Extremities : leg swelling -|- warm acral +|+,
pupil isokor +/+, reflek cahaya +/+ CRT < 2 sec
JVP R+0 cmH2O
 PENGOBATAN SAAT INI
1. Levofloxacin 1x500mg
2. Revatio 3s20mg
3. Dorner 3x20mg
4. Xarelto 2x15mg
5. Atorvastatin 1x20mg
6. Aspilet 1x80mg
7. Ramipril 1x5mg
8. Diltiazem 3x60mg
9. Spironolactone 1x25mg
10.Furosemide 2x40mg
Hasil Konferens 20 Mei 2021
Dilakukan pemeriksaan DUS extremitas inferior evaluasi, CT scan vascular
abdomen dengan kontrast dan CT scan thorax tanpa kontrast persiapan
pulmonary endarterectomy

KIE kepada pasien dan keluarga terkait risk & benefit tindakan invasive maupun
konservatif. Memastikan persetujuan pasien dan keluarga terkait rencana
tindakan inavasive strategy.
THANK YOU