contoh Morning Report Kardio

1. Morning Report
Thursday, Desember 06th 2018
Zam
Tihar
Paskal
Maya
Zulkarnain
Hendry
Ofel

2. 1. Congestive Heart Failure NYHA III
2. Unstable Angina Pectoris
3. Unstable Angina Pectoris
4. ST Elevation Myocardial Infarction Extensive Anterior Onset
4 hours Killip II
5. ST Elevation Myocardial Infarction Inferoposterior + RV wall
Onset 6 hours Killip I
6. Non ST Elevation Myocard Infarct High Risk, Shock
hipovolemic dd Shock Sepsis

3. 1st Patient
Name : Mr. Zainuddin
Date of Birth : 15/06/1972 (46 y.o)
Address : Makassar
Date of Admission : December 06th, 2018
DPJP : IM

4. History Taking
• Chief Complaint : Shortness of Breath
• Shortness of breath was felt since 4 days ago, worsened 1 day before admission. DOE
(+), Ortopnea (+), PND (+).
• History of hospitalization in September 2018 at PJT with similar symptom.
• There was history of PCI in March 2017
• Coronary risk factor :
– There was history of smoking, 1-2 packs/day, but stopped since 1 year ago
– There was history of diabetes for 5 years, taking regular medicine with insulin
• Routine Medication: Miniaspi 80mg, Atorvastatin 20mg, Spironolacton 25mg,
Captopril 25mg, Novorapid 24 unit, Levmir 28 unit.

5. Physical Examination
• BP: 167/100 mmHg, HR : 100 bpm Regular, RR : 26 tpm, T:
36,20C, O2 saturation 98%
• Conjunctiva not anemic, sclera not icteric
• JVP R+4 cmH2O
• Vesicular breath sound, decreased in both base hemithorax
Rales on mediobasal bilateral
• S1/ S2 Regular, No audible murmur
• Abdominal : normal peristaltic sounds, Ascites (+)
• Extremity: warm, oedema at inferior extremity et superior
extremity bilateral

6. ECG at Cardiac Center
06/12/2018
• Sinus Rhythm, HR 96 bpm, axis 10°, P wave 0,10 s, PR int 0.20 s, RsR’ at V5-V6
• Conclusion : Sinus rhytm, normoaxis, ICLBBB

7. Laboratory Findings
06/12/2018
WBC 9.500 103/mm3 4-10 x 103/mm3
N/L/M/E/B 68.7 / 21.4 / 5.0 / 4.1 / 0.8
HGB 11.8 g/dl 12-16
HCT 35.5 % 37,0-48,0
PLT 269 103/mm3 150-400 x 103/mm3
RBG 383 mg/dl 140
SGOT 15 U/L < 38
SGPT 16 U/L < 41
UREUM 33 mg/dl 10-50
KREATININ 2.01 mg/dl L(<1,3) P<(1,1)
eGFR 51.9
PT/APTT 9.4 / 20.3 second 10-14/22,0-30,0
INR 0.78 - -
Na 140 mmol/L 136-145
K 3.1 mmol/L 3,5-5,1
Cl 106 Mmol/L 97-111

8. Chest Xray
06/12/2018
Normal bronkhovascular marking
• Cor with CTI approximately 0.62,
Grounded apex
• Blunt both of costophrenic sinus
• Intact Bone
• Normal soft tissue
Conclusion :
• Cardiomegaly with pulmonary edema
• Bilateral pleura effusion

9. Echocardiography
06-12-2018
• Decreased Systolic Function of LV, EF 23.1% (Teich), 22.1% (Biplane)
• Cardiac chamber : Dilatation all chamber, LV SEC
• (LVEDd : 6.03 cm, LVEDs: 5.38 cm LA Mayor : 6.4 cm, LA Minor : 4.5 cm, RA Mayor
5.9 cm, RA Minor 4.2 cm, RVDB 3.2 cm, Ao 2.6 cm, LA 4.2 cm, LA/Ao 1.62)
• Left ventricle hypertrophy: (+) Eccentric (LVMI 119 g/m2, RWT 0.33)
• Myocardial Movement : Akynetic basal anterolateral, mid inferior, inferolateral,
apicoanterior, apicoinferior, Hypokinetic at other segment
• Normal RV systolic function, TAPSE 2.4 cm
• Cardiac Valves :
• Mitral : Mild MR (MR ERO 0.25 cm2, MR RV 28 ml)
• Aorta : 3 cuspis. Calcification (+), RCC
• Tricuspid : TR trivial
• Pulmonal : Mild PR
• E/A > 2
• eRAP 15 mmHG, (2.4/1.0), LVSV 39 ml, LVCO 3.7 ml/min, SVR 2314 dynes/sec/cm5
Conclusion
• Decreased LV Systolic function, EF 22.1% (Biplane)
• Dilatation all chamber, LV SEC
• LVH eccentric
• Segmental akynetic and hypokinetic
• Mild MR
• Diastolic dysfunction LV gr.III

10. Assessment
• Congestive Heart Failure NYHA III
• Coronary Artery Disease 3 Vessels Disease
• Hypertensive Heart Disease
• Diabetes Mellitus type 2
• Efusi Pleura Bilateral
• Hipokalemia

11. Management
• Furosemide 40mg/intravenous
 10mg/hours/Syringepump
• Nitrogliserin 10 mcg/minute/Syringepump
• Miniaspi 80mg/24 hours/oral
• Atorvastatin 20mg/24 hour/oral
• Spironolactone 25mg/24 hours/oral
• Captopril 25mg/8 hours/oral
• Novorapid 24-24-24 unit/subutan
• Levemir 0-0-28 unit/Subcutan

12. Plan
• Transfer to Ward
• Profil lipid, FBG, Hba1c
• Consult to EMD Division

13. 2nd Patient
Name : Mr. Kaswadi
Date of Birth : 13-09-1976 (42 y.o)
Address : Makassar
Date of Admission : December 06th, 2018
DPJP : IM
Patient was referred from Enrekang Hospital with
diagnosed UAP, DM Type 2, Hypertension

14. History Taking
• Chief Complaint : Chest Pain
• Chest pain was felt since 30 hours before admission, pressed-like sensation, radiated to
back, duration > 20 min, accompanied with diaphoresis and nausea. No history of chest
pain before.
• There was no complaint of shortness of breath.
• There was history of syncope period for 15 minutes during transport. History of near
syncope several times in the last 2 years.
• Coronary risk Factor :
– History of DM known since 2 years ago, regularly taking insulin.
– History of hypertension known since 3 month ago, not taking medicine regularly.
• Medication from Enrekang Hospital: Miniaspi 80 mg, Clopidogrel 75mg,
Irbesartan 150mg, Simvastatin 20mg, ISDN 5mg, Omeprazole 40mg IV,
Levemir 0-0-22 unit, Novorapid 22-22-22 unit

15. Physical Examination
• GCS 15 (E4M5V6)
• BP: 174/108 mmHg, HR : 102 bpm regular, RR : 20 tpm, T:
36,40C
• Conjunctiva not anemic, sclera not icteric
• JVP R+2 cmH2O
• Vesicular breath sound, No rales and wheezing
• S1/ S2 regular, No audible murmur
• Abdominal : normal peristaltic sounds, Ascites (-)
• Extremity: warm, no oedema

16. ECG at Enrekang Hospital
06/12/2018
Sinus rythm, HR 100 bpm, P duration 0.08s, PR Interval 0.16s, QRS
Duration 0.08s
Conclusion : Sinus rythm, normoaxis

17. ECG at PJT
06/12/2018
Sinus rythm, HR 107 bpm, axis 20°, P duration 0.08s, PR Interval 0.16s, QRS
Duration 0.08s
Conclusion : Sinus Tachycardia, normoaxis

18. Laboratory Findings
06/12/2018
WBC 12.500 103/mm3 4-10 x 103/mm3
N/L/M/E/B 60.5 / 29 / 9.2 / 0.9 / 0.05
HGB 13.8 g/dl 12-16
HCT 39.8 % 37,0-48,0
PLT 341 103/mm3 150-400 x 103/mm3
RBG 263 mg/dl 140
SGOT 18 U/L < 38
SGPT 37 U/L < 41
UREUM 23 mg/dl 10-50
KREATININ 0.71 mg/dl L(<1,3) P<(1,1)
PT/APTT 9.3/21.8 second 10-14/22,0-30,0
INR 0.77 - -
CK 167.16 U/L L (< 190)
CK-MB 30.4 U/L < 25
Hs Troponin I 9.6 ng/l L (17-50)
Na 140 mmol/L 136-145
K 4.3 mmol/L 3,5-5,1
Cl 104 Mmol/L 97-111

19. Chest Xray
06/12/2018
Normal bronchovascular marking
• Cor with CTI approximately 0.47
• Normal both of costophrenic sinus and
diaphragm
• Intact Bone
• Normal soft tissue
Conclusion :
• Normal Cor and Pulmonal

20. Echocardiography
06-12-2018
• Normal Systolic Function of LV, EF 64.7% (Teich), 60.0% (Biplane)
• Cardiac chamber : Normal
• (LVEDd : 4.8 cm, LVEDs: 3.13 cm LA Mayor : 4.3 cm, LA Minor : 2.8 cm, RA Mayor 4.3 cm, RA
Minor 2.9 cm, RVDB 2.2 cm, Ao 2.5 cm, LA 3.2 cm, LA/Ao 1.28)
• Left ventricle hypertrophy: Consentric remodelling (LVMI 97.6 g/m2, RWT 0.5)
• Myocardial Movement : Global normokinetic
• Normal RV systolic function, TAPSE 1.8 cm
• Cardiac Valves :
• Mitral : Normal Function and movement
• Aorta : 3 cuspis. Calcification (-), Normal Function and movement
• Tricuspid : Normal Function and movement
• Pulmonal : Normal Function and movement
• E/A < 1
• eRAP 8 mmHG, (IVC expirasi 1.3, Inspirasi 0.8)
• LVSV 56 ml, LVCO 5.4 ml/min, SVR 1807 dynes/sec/cm5
Conclusion
• Normal LV Systolic function, EF 60% (Biplane)
• LV Diastolic disfunction gr.I

21. Assessment
• Unstable Angina Pectoris
Grace Score 54, Low Risk (< 1%) in hospital mortality
• Diabetes Melitus Type 2
• Post Syncope

22. Management
• NTG 10mcg/minute/syringepump
• Miniaspi 80mg/24 hours/oral
• Clopidogrel 75mg/24 hours/oral
• Atorvastatin 40mg/24 hours/oral
• Irbesartan 150mg/24 hours/oral
• Arixtra 2.5mg/24 hours/subcutan
• Levemir 0-0-22 unit/subcutan
• Novorapid 22-22-22 unit/subcutan

23. Plan
• Transfer to HCU
• Profil Lipid, FBG, Hba1C
• Consult to EMD Division
• Exercise Stress Test

24. 3rd Patient
Name : Mr. Azis Koddeng
Date of Birth : 01-07-1949 (69 y.o)
Address : Makassar
Date of Admission : December 06th, 2018
DPJP : IM

25. History Taking
• Chief Complaint : Chest Discomfort
• Chest discomfort was felt since 2.5 hours before admission, pressed-like sensation,
radiated to left arm, duration > 20 min, accompanied with diaphoresis. There
was history of chest discomfort intermittently since 1 week ago .
• There was no complaint of shortness of breath.
• There was history of Coronary Angiography in September 2018 with CAD 3VD
• Coronary risk Factor :
– Patient still smoking 2-3 packs/day.
– History of hypertension known since 5 years ago, taking medicine regularly.
• Routine Medication: Spironolactone 25mg, Amlodipine 10mg,
Furosemide 40mg, Ramipril 5mg, Miniaspi 80mg, Nitrokaf 2.5mg,
Atorvastatin 20mg

26. Physical Examination
• BP: 191/95 mmHg, HR : 60 bpm Regular, RR : 20 tpm, T:
36.30C
• Conjunctiva not anemic, sclera not icteric
• JVP R+2 cmH2O
• Vesicular breath sound, no rales nor wheezing
• S1/ S2 Regular, No audible of murmur
• Abdominal : Soepel, normal peristaltic sounds
• Extremity: warm, no oedema

27. ECG at PJT
06/12/2018
Sinus Rhythm, HR 54 bpm, axis 0°, P duration 0.08s, PR interval 0.20s, QRS duration 0.08s, ST
depression V2-V3, Tinverted V3-V6, I, aVL
Conclusion : Sinus bradicardia, Normoaxis, Ischemic anterolateral wall

28. Laboratory Findings
06/12/2018
WBC 7.300 103/mm3 4-10 x 103/mm3
N/L/M/E/B 47.7 /40.8 / 8.2 / 2.6 / 0.7
HGB 10.8 g/dl 12-16
HCT 31 % 37,0-48,0
PLT 217 103/mm3 150-400 x 103/mm3
GDS 106 mg/dl 140
SGOT 15 U/L < 38
SGPT 12 U/L < 41
UREUM 47 mg/dl 10-50
KREATININ 1.15 mg/dl L(<1,3) P<(1,1)
PT/APTT 10.1/26.3 second 10-14/22,0-30,0
INR 0.84 - -
CK 107.86 U/L L (<190)
CK-MB 17.6 U/L <25
Hs Tropnin I 20.0 ng/l L (17-50)
Na 141 mmol/L 136-145
K 4.1 mmol/L 3,5-5,1
Cl 109 Mmol/L 97-111

29. Chest Xray
06/12/2018
Normal bronkhovascular marking
• Cor with CTI approximately 0.73
with Grounded apex
• Blunt at left of costophrenic sinus
• Intact Bone
• Normal soft tissue
Conclusion :
• Cardiomegaly
• Left pleura effusion

30. Echocardiography
06-12-2018
• Decreased Systolic Function of LV, EF 50.0 % (Teich), 47.2% (Biplane)
• Cardiac chamber : LV Dilatation
• (LVEDd : 6.39 cm, LVEDs: 4.74 cm LA Mayor : 5.7 cm, LA Minor : 4.6 cm, RA Mayor
4.3 cm, RA Minor 3.7 cm, RVDB 2.6 cm, Ao 3.0 cm, LA 4.4 cm, LA/Ao 1.47)
• Left ventricle hypertrophy: (+) Eccentric (LVMI 184 g/m2, RWT 0.34)
• Myocardial Movement : Hypokinetic mid basal, inferior, inferolateral, apicoinferior
• Normal RV systolic function, TAPSE 2.1 cm
• Cardiac Valves :
• Mitral : Moderate MR (MR ERO 0.19 cm2, MR RV 50 ml)
• Aorta : 3 cuspis. Calcification (+), RCC, Mild AR (AR PHT 31 ms)
• Tricuspid : Normal Function and movement
• Pulmonal : Normal Function and movement
• E/A < 1
• eRAP 3 mmHG, (1.5/0.7), SV 102 ml, CO 8.9 ml/min, SVR 1115 dynes/sec/cm5
Conclusion
• Decreased LV Systolic function, EF 47.2% (Biplane)
• LV Dilatation
• LVH eccentric
• Segmental hypokinetic
• Moderate MR, Mild AR
• Dyastolic disfunction LV gr.I

33. Assessment
• Unstable Angina Pectoris
Grace Score 78, Low Risk (<1%) in hospital mortality
• Coronary Artery Disease 3 Vessels Disease

34. Management
• Loading DAPT
• Aspilet 80mg/24 hours/oral
• Clopidogrel 75mg/24 hours/oral
• NTG 20mcg/minute/syringepump
• Captopril25mg/8 jam/oral
• Atorvastatin 40mg/24 hours/oral
• Fondaparinux 2.5mg/24 hours/subcutan

35. Plan
• Transfer to CVCU
• Profil lipid

36. 4th Patient
Name : Mrs. Nuraeni
Date of Birth : 25-12-1964 (53 y.o)
Address : Batara Bira
Date of Admission : December 06th, 2018
DPJP : IM
Patient was referred from RSUD Daya with diagnosed
ACS, DM Type 2

37. History Taking
• Chief Complaint : Chest Pain
• Chest pain was felt since 4 hours before admission, pressed-like sensation, radiated to
back, duration > 20 min, accompanied with diaphoresis and nausea.
• There was no complaint of shortness of breath.
• Coronary risk Factor :
– History of DM known since 5 years ago, regularly taking insulin.
– History of hypertension known since 5 years ago, not taking medicine regularly.
• Medication from RSUD Daya: Aspilet 80 mg, Clopidogrel 75mg, ISDN 5mg,
Bisoprolol 2.5mg

38. Physical Examination
• GCS 15 (E4M5V6)
• BP: 138/86 mmHg, HR : 60 bpm regular, RR : 20 tpm, T:
36,70C
• Conjunctiva not anemic, sclera not icteric
• JVP R+2 cmH2O
• Vesicular breath sound, rales at basal of lung, wheezing (-)
• S1/ S2 regular, No audible murmur
• Abdominal : normal peristaltic sounds, Ascites (-)
• Extremity: warm, no oedema

39. ECG at RSUD Daya
06/12/2018
Sinus rythm, HR 62 bpm, axis 60°, P duration 0.10s, PR interval 0.16s, QRS
Duration 0.06s, ST elevation V1-V6, I, aVL
Conclusion : Sinus Rythm, normoaxis, Acute extensive anterior wall myocardial
infarction

40. ECG at PJT
06/12/2018
Sinus rythm, HR 60 bpm, axis 60°, P duration 0.08s, PR Interval 0.16s, QRS
Duration 0.08s, ST elevation V1-V6, I, aVL
Conclusion : Sinus Rythm, normoaxis, Acute extensive anterior wall myocardial
infarction

42. Laboratory Findings
06/12/2018
WBC 16.500 103/mm3 4-10 x 103/mm3
N/L/M/E/B 72.3 / 22.7 / 4.1 / 0.5 / 0.4
HGB 13.0 g/dl 12-16
HCT 37 % 37,0-48,0
PLT 315 103/mm3 150-400 x 103/mm3
RBG 342 mg/dl 140
SGOT 22 U/L < 38
SGPT 25 U/L < 41
UREUM 30 mg/dl 10-50
KREATININ 0.70 mg/dl L(<1,3) P<(1,1)
PT/APTT 9.9/21.3 second 10-14/22,0-30,0
INR 0.82 - -
CK 84.86 U/L L (< 190)
CK-MB 18.5 U/L < 25
Hs Troponin I 115.3 ng/l P (8-29)
Na 138 mmol/L 136-145
K 3.6 mmol/L 3,5-5,1
Cl 102 Mmol/L 97-111

43. Echocardiography
06-12-2018
• Decreased Systolic Function of LV, EF 45.6% (Teich)
• Cardiac chamber : Normal
• (LVEDd : 4.4 cm, LVEDs: 3.4 cm LA Mayor : 5.3 cm, LA Minor : 3.6 cm, RA Mayor 4.3 cm, RA
Minor 2.4 cm, RVDB 2 cm
• Left ventricle hypertrophy: (-) (LVMI 72 g/m2, RWT 0.33)
• Myocardial Movement : Hypokinetic basal mid anterior, anterolateral, apicoanterior, apicoseptal,
apicolateral
• Normal RV systolic function, TAPSE 1.9 cm
• Cardiac Valves :
• Mitral : Normal Function and movement
• Aorta : 3 cuspis. Calcification (-), Normal Function and movement
• Tricuspid : Normal Function and movement
• Pulmonal : Normal Function and movement
• E/A > 1 Normal
• eRAP 8 mmHG, (IVC expirasi 2, Inspirasi 1.5)
• LVSV 49 ml, LVCO 3.1 ml/min
Conclusion
• Decreased LV Systolic function, EF 45% (TEICH)
• Hypokinetic segmental

44. Assessment
• ST Elevation Myocardial Infarction Extensive
Anterior Onset 4 hours Killip II
TIMI Risk Score 5, 12.4% Estimated 30-day Mortality
• Diabetes Melitus Type 2

45. Management
• Actylise 15mg/intravenous
 50mg/30 minute/syringepump
 35mg/60 minute/syringepump
• Aspilet 80mg/24 hours/oral
• Clopidogrel 75mg/24 hours/oral
• Atorvastatin 40mg/24 hours/oral
• Captopril 12.5mg/8 hours/oral
• NTG 10mcg/minute/syringepump
• Furosemide 40 mg/12 hours/iv
• Novorapid 8-8-8 unit/subcutan
• Levemir 0-0-12 unit/subcutan

46. Plan
• Early PCI if indicated after
fibrinolitk
• Transfer To CVCU
• Profil Lipid, FBG, Hba1C
• Consult to EMD Division

47. 5th Patient
Name : Mrs. Titin
Date of Birth : 03-10-1957 (61 y.o)
Address : Makassar
Date of Admission : December 06th, 2018
DPJP : AAU
Patient was referred from Sidrap Hospital with
diagnosed ACS

48. History Taking
• Chief Complaint : Chest Pain
• Chest pain was felt since 6 hours before admission, pressed-like sensation, radiated to
left arm, duration > 20 min, accompanied with diaphoresis and nausea. There was
history of chest pain intermittently since 1 year ago.
• There was no complaint of shortness of breath.
• Coronary risk Factor :
– History of hypertension known since 2 years ago, taking medicine regularly.
• Medication from Sidrap Hospital: Clopidogrel 75mg, ISDN 5mg, Omeprazole
40mg, Ketorolac 30mg

49. Physical Examination
• GCS 15 (E4M5V6)
• BP: 115/70 mmHg, HR : 71 bpm regular, RR : 20 tpm, T:
36,70C
• Conjunctiva not anemic, sclera not icteric
• JVP R+2 cmH2O
• Vesicular breath sound, no rales and wheezing
• S1/ S2 regular, No audible murmur
• Abdominal : normal peristaltic sounds, Ascites (-)
• Extremity: warm, no oedema

50. ECG at Sidrap Hospital
06/12/2018
Sinus rythm, HR 57 bpm, axis 45°, P duration 0.08s, PR interval 0.20s, QRS
Duration 0.08s, ST elevation II,III,aVF
Conclusion : Sinus Bradikardia, normoaxis, Acute inferior wall myocardial
infarction

51. ECG at PJT
06/12/2018
Sinus rythm, HR 65 bpm, axis 70°, P duration 0.08s, PR Interval 0.20s, QRS
Duration 0.08s, ST elevation II,III,aVF
Conclusion : Sinus Rythm, normoaxis, Acute inferior wall myocardial
infarction

52. ECG at PJT
06/12/2018
Posterior
Sinus rythm, HR 62 bpm, axis 70°, P duration 0.08s, PR Interval 0.20s, QRS
Duration 0.08s, ST elevation II,III,aVF, V4R, V8-V9
Conclusion : Sinus Rythm, normoaxis, Acute inferoposterior wall + RV
myocardial infarction

53. ANTERIOR

54. POSTERIOR

55. Laboratory Findings
06/12/2018
WBC 12.400 103/mm3 4-10 x 103/mm3
N/L/M/E/B 82/ 14.6 / 2.7 / 0.2 / 0.5
HGB 10.2 g/dl 12-16
HCT 29 % 37,0-48,0
PLT 198 103/mm3 150-400 x 103/mm3
RBG 182 mg/dl 140
SGOT 30 U/L < 38
SGPT 25 U/L < 41
UREUM 25 mg/dl 10-50
KREATININ 0.60 mg/dl L(<1,3) P<(1,1)
PT/APTT 10.3/22.8 second 10-14/22,0-30,0
INR 0.85 - -
CK 112.54 U/L L (< 190)
CK-MB 27.2 U/L < 25
Hs Troponin I 252.6 ng/l P (8-29)
Na 133 mmol/L 136-145
K 3.8 mmol/L 3,5-5,1
Cl 98 Mmol/L 97-111

56. Echocardiography
06-12-2018
• Decreasd Systolic Function of LV, EF 48.6% (Teich)
• Cardiac chamber : Normal
• LVEDd : 4.2 cm, LVEDs: 3.1 cm LA Mayor : 5.2 cm, LA Minor : 3.7 cm, RA Mayor 5.1 cm, RA Minor
2.7 cm, RVDB 2.1 cm
• Left ventricle hypertrophy: Consentric (LVMI 97.6 g/m2, RWT 0.5)
• Myocardial Movement : Hypokinetic basal mid inferoseptal, inferior, inferolateral, apicoinferior
• Decreased RV systolic function, TAPSE 1.3 cm
• Cardiac Valves :
• Mitral : Normal Function and movement
• Aorta : 3 cuspis. Calcification (-), Normal Function and movement
• Tricuspid : Normal Function and movement
• Pulmonal : Normal Function and movement
• E/A < 1
• eRAP 8 mmHG, (IVC expirasi 1.9, Inspirasi 1.5)
• LVOT VTI 15.8, LVSV 40 ml, LVCO 3.4 ml/min
Conclusion
• Decreased LV & RV Systolic function, EF 48.6% (TEICH)
• LVH Consetric
• Hypokinetic Segmental
• LV Diastolic disfunction gr.I

57. Assessment
• ST Elevation Myocardial Infarction Inferoposterior
+ RV wall Onset 6 hours Killip I
TIMI Risk Score 2, 2.2% Estimated 30-day Mortality

58. Management
• IVFD NaCl 0.9 % 2000 cc
• Actylise 15mg/intravenous
 50mg/30 minute/syringepump
 35mg/60 minute/syringepump
• Loading DAPT
• Aspilet 80mg/24 hours/oral
• Clopidogrel 75mg/24 hours/oral
• Atorvastatin 40mg/24 hours/oral

59. Plan
• Coronary Angiography
• Transfer To CVCU
• Profil Lipid

60. 6th Patient
Name : Mrs. Murniati
Date of Birth : 06-03-1973 (45 y.o)
Address : Makassar
Date of Admission : December 06th, 2018
DPJP : AA
Patient was referred from RS Faisal with diagnosed
Unstable Supraventricle Tachycardia

61. History Taking
• Chief Complaint : Decrease of consciousness
• Decrease of consciousness was felt 3 hours before admission, previously patient was
transferred from RS Faisal after period of Supraventricle Tachycardia.
• From heteroanamnesis, patient felt chest pain in retrosternal and radiated to back and
left arm started 2 hours before admission at RS Faisal
• In RS Faisal, patient was given Amiodarone and performed Cardioversion
• Patient have a history of diabetes for undetermined period and not taking regular
medication
• Medication from Faisal Hospital: Amiodarone 150 mg iv, digoxin 0.5 mg iv,
Farsorbid 5 mg sl, Dobutamin 5 mcg

62. Physical Examination
• GCS 13 (E4M5V3)
• BP: 70/40 mmHg, HR : 145 bpm regular, RR : 30 tpm, T:
360C
• Conjunctiva not anemic, sclera not icteric
• JVP R+2 cmH2O
• Vesicular breath sound, no rales and wheezing
• S1/ S2 regular, murmur can not be evaluated
• Abdominal : normal peristaltic sounds, Ascites (-)
• Extremity: cold, wet

63. ECG at RS Faisal
06/12/2018
Supraventricular rythm, HR 168 bpm, axis 170°, QRS Duration 0.06s
Conclusion : Atrial Tacycardia dd Atypical AVNRT

64. ECG at PJT
06/12/2018
Sinus rythm, HR 150 bpm, axis 75°, P duration 0.06s, PR Interval 0.16s, QRS
Duration 0.04s
Conclusion : Sinus Tachycardia, normoaxis

65. Laboratory Findings
06/12/2018
WBC 41400 103/mm3 4-10 x 103/mm3
N/L/M/E/B 84.2/ 4.8 / 10.1 / 0.0 / 0.9
HGB 14 g/dl 12-16
HCT 43 % 37,0-48,0
PLT 538 103/mm3 150-400 x 103/mm3
RBG 622 mg/dl 140
SGOT 58 U/L < 38
SGPT 10 U/L < 41
UREUM 37 mg/dl 10-50
KREATININ 1.10 mg/dl L(<1,3) P<(1,1)
PT/APTT 12.4/60.9 second 10-14/22,0-30,0
INR 1.03 - -
CK 41.31 U/L L (< 190)
CK-MB 68.5 U/L < 25
Hs Troponin I 111.5 ng/l P (8-29)
Na 135 mmol/L 136-145
K 4.6 mmol/L 3,5-5,1
Cl 104 Mmol/L 97-111

66. Echocardiography
06-12-2018
• Decreased Systolic Function of LV, EF 41.9% (Teich)
• Cardiac chamber : LV Dilatation
• LVEDd : 5.1 cm, LVEDs: 4 cm LA Mayor : 5 cm, LA Minor : 3.8 cm, RA Mayor 3.5 cm, RA Minor 2.3
cm, RVDB 2.1 cm
• Left ventricle hypertrophy: Eccentric (LVMI 95.1 g/m2, RWT 039)
• Myocardial Movement : Hypokinetic basal mid anterior, anteroseptal, anterolateral, apicoanterior,
apicoseptal
• Normal RV systolic function, TAPSE 1.7 cm
• Cardiac Valves :
• Mitral : Normal Function and movement
• Aorta : 3 cuspis. Calcification (-), Normal Function and movement
• Tricuspid : Normal Function and movement
• Pulmonal : Normal Function and movement
• E/A on Tachicardia
• eRAP 3 mmHG, (IVC expirasi 1.7, Inspirasi 0.7)
• LVOT VTI 14.2, LVSV 45 ml, LVCO 6.1 ml/min
Conclusion
• Decreased LV Systolic function, EF 41.9% (TEICH)
• LV Dilatation
• LVH Eccentric
• Segmental hypokinetic

67. Assessment
•Non ST Elevation Myocard Infarct High
Risk
•Shock hipovolemic dd Shock Sepsis
• Diabetic Ketoacidosis dd HONK

68. Management
• IVFD Nacl 0.9% 2000 cc and maintenance with
2000 cc / 24 hours / drips
• Ceftriaxone 2 gram/ 24 hour / iv
• Aspilet 160 mg/ Extra / oral ~ Aspilet 80 mg/ 24
hour / oral
• Clopidogrel 300 mg/ Extra/ oral ~ Clopidogrel 75
mg / 24 hour / oral
• Atorvastatin 40 mg/ 24 hour / oral
• Arixtra 2.5 mg/ 24 hour / subcutan

69. Plan
• Consult to EMD
• Transfer To CVCU
• GDP, GD2PP, HbA1C

70. EMD Division
• Dx : Susp Ketoacidois Diabetic
• Th / :
– Fluid Rehydration 0.9% 2 liters
– Yale Protocol of Insulin
– Target RBG 140-180 mg/dl
– Bolus Insulin 5 IU / hour / syringepump
– GDS 450 – 549 : 5 IU / hours / sp
– GDS 350 – 449 : 4 IU / hours / sp
– GDS 250 – 349 : 3 IU / hours / sp
– GDS 150 – 249 : 2 IU / hours / sp
– GDS 100 – 149 : 1 IU / hours / sp

71. •THANK YOU