case report

1. Morning Report
Date : Friday, February 9th 2024
Physician in Charge
IV : dr. Yola, dr. Noval
IIIA (Ward/IW) : dr. Afif, dr. Fitri
IIIB : dr. Anastasia, dr. Aswin, dr. Jauhar
IIA : dr. Akita, dr. Cik
IIB : dr. Gallusena
Consultant on Duty : dr. Wella Karolina, Sp.JP(K)
MR Consultant : Prof. dr. M. Saifur Rohman, Sp.JP(K), Ph.D

2. SUBJECTIVE
Mrs. K/68 yo/11606790
The patient was referred from the PACCE clinic with TAVB
CHIEF COMPLAINT: Dizziness
The patient suffered from dizziness since 2 weeks ago, but it got worse at 05.00 AM (9/2/2024, 6 hours before admission to PACCE
clinic). The complaint was accompanied by near syncope, dyspnea, chest discomfort, cold sweating, and body weakness. She also
complained of nausea and vomiting. There were no involuntary movement of his bilateral extremities with lack of coordination and
confusion. These complaints were also not related to any postural changes, urination, neck pressure, or head turning. History of DOE
since the last 1 year while doing moderate activities. There were no history of OE, PND, or palpitation. Because of these complaints, her
family brought her to PACCE clinic.
The patient arrived at PACCE clinic at 11.00 AM (9/2/2024), the patient still complained of dizziness, with hemodynamic BP 200/80
mmHg, HR 30-40 bpm, RR 22-24 tpm, SpO2 94% RA. The ECG showed TAVB. She got sulfate atropine 3 mg in total, but the heart rate did
not improve, and then she was given drip Dopamine 5 mcg/kgBW/min. Because there was no improvement, she was suggested to be
referred to RSSA for TPM installation.
At ER RSSA 06.15 PM (9/2/2024), the dizziness persisted, with hemodynamic BP 158/100 mmHg, HR 30-40 bpm on Drip Dopamin 5
mcg/kgBW/min. ECG was performed and showed TAVB with couplet PVC episode. From HS troponin was increasing. Then patient sent to
the Cathlab for TPM installation and Invasive Strategy also admitted to CVCU for further monitoring and evaluation.

3. SUBJECTIVE
Mrs. K/68 yo/11606790
PAST MEDICAL HISTORY:
• HT (+) since 1 year ago, not consuming her medication regularly (Captopril 3x25mg, Amlodipine 1x5mg)
• History of DOE (+) the last 1 year
• History of Chest pain while doing heavy activities
• History of DM, CVA, PND, OE, leg edema were denied
RISK FACTORS:
• HT (+) since 1 year ago (uncontrolled)
• Menopause (+)
FAMILY HISTORY :
She is the fourth child among four siblings
Her parents passed away at 60 yo because of geriatric problems, without any history of HT, DM, Cardiac disease, or CVA
No history of HT, DM, or CVA in her siblings
There is no history of sudden cardiac death in her family

4. Subjective
Mrs. K/68 yo/11606790
SOCIAL HISTORY:
She works as a housewife with mild-moderate activities, there is no limiting activity.
SCREENING OF COVID-19
There was no cough, fever, sore throat, anosmia, or dysgeusia in the last 14 days
History of traveling to red zone area was denied
History of contact with patient confirmed COVID-19 was denied
TREATMENT HISTORY IN PREVIOUS HOSPITAL:
Inj. Sulfate Atropine 3mg
Drip Dopamine 5mcg/kgBW/minute
Miniaspi 1x80mg
Simvastatin 1x20mg
Amlodipine 1x5mg
Candesartan 1x16mg

5. OBJECTIVES
PHYSICAL EXAMINATION
General appearance moderate ill
Weight 65 kg Height 150 cm BMI 28.9 kg/m2 (Obese grade I)
GCS E4 V5 M6
Vital Sign
BP : 158/100 mmHg
HR : 20-30 x/ minute
RR : 22 x/ minute
SpO2 : 98% on NC 3-4 lpm
Tax : 36.7oC
Head and Neck
Pale conjunctiva -/-, icteric sclera -/-
JVP R+1 cmH2O
Thorax
Symmetrical, retraction (-)
Cor:
Ictus cordis palpable at ICS V 1 cm lat MCL sin, heaves (-), thrill (-),
LHM at apex, RHM at sternal line. Heart sound S1-S2 normal
regular, murmur (+), Pansistolik murmur 4/6 SIC 5 mid clavicula
Pulmo:
Ves/ves Rh -/- Wh - /-
Ves/ves -/- - /-
Ves/ves -/- - /-
Abdomen
Soepel, Hepar and lien unpalpable, Hepatojugular reflux (-)
Bowel sounds normal, bruits (-)
Extrimities
Edema - / -
- / -
Leg swelling -|-, warm acrals, CRT < 2s, strong pulse regular
UOP: 1700 cc/7 hours

6. OBJECTIVES – ECG at PACCE Clinic
TAVB, atrial rate 100 bpm, ventricular rate
37 bpm, FA N, HA CCWR, QRS dur 130
ms, ST changes (-), inverted T at leads I,
aVL, V2-V6
Conclusion:
TAVB, HR 37 bpm with junctional escape
rhythm, complete RBBB
February 09th 2024 at 10.17 AM
Calibration: 10 mm/mV 25 mm/s

7. OBJECTIVES – ECG at PACCE Clinic (Post SA 3mg)
TAVB, atrial rate 100 bpm, ventricular rate
40 bpm, FA N, HA CCWR, QRS dur 130
ms, ST changes (-), inverted T at leads I,
aVL, V2-V6
Conclusion:
TAVB, HR 40 bpm with junctional escape
rhythm, complete RBBB
February 09th 2024 at 02.00 PM
Calibration: 10 mm/mV 25 mm/s

8. OBJECTIVES – ECG at RSSA
TAVB, atrial rate 100 bpm, ventricular rate
20-30 bpm, FA N, HA CCWR, QRS dur 120
ms, ST changes (-), inverted T at leads I,
aVL, PVC (+)
Conclusion:
TAVB, HR 20-30 bpm with junctional
escape rhythm, PVC RVOT origin
inferior axis with PVC couplet episode +
complete RBBB
February 09th 2024 at 06.39 PM
Calibration: 10 mm/mV 25 mm/s

9. OBJECTIVES – CXR
CXR at RSSA February 09th 2024
INTERPRETATION
• AP position, symmetrical, enough KV, enough inspiration
• Trachea: in the middle
• Bone: intact, no osteolytic/osteoblastic lesions/fracture lines
• Soft tissue: normal
• Aorta: aortic calcification (-), dilatation(-), elongation(-)
• Heart: cardiomegaly CTR 76%, cardiac waist (-), apex
embedded
• Lungs: bronchovesicular pattern was normal, hilus dextra and
sinistra normal, infiltrate (-), consolidation (+) at lung sinistra
and dextra
• Costophrenic angle dextra and sinistra were sharp
• Hemidiaphragm dextra and sinistra were dome-shaped
Conclusion :
Cardiomegaly
Mediastinum dilatation
Lung fibrosis

10. OBJECTIVES – LABORATORY EXAMINATION
Laboratory Findings at PACCE Clinic February 09th 2024
Parameter Result Normal Value
Hb 12.5 g/dL 13.4 – 17.7 g/dL
Leukocytes 12.670 /µL 4300-10300/µL
Hematocrit 35.4 % 40 – 47 %
Thrombocytes 209000 /µL 142000-424000/µL
Differential count 0/3/56/32/7 0-4/0-1/51-67/25-33/2-5
%
Ureum 44.5 mg/dl 16.6 – 48.5 mg/dL
Creatinine 1.6 mg/dl 0.67 – 1.17 mg/dL
GDS 134 mmol/L <200

11. OBJECTIVES – LABORATORY EXAMINATION
Laboratory Findings at RSSA February 09th 2024
Parameter Result Normal Value
Hb 13.2 g/dL 13.4 – 17.7 g/dL
Leukocytes 15040 /µL 4300-10300/µL
Hematocrit 38.3 % 40 – 47 %
Thrombocytes 243000 /µL 142000-424000/µL
MCV 86.5 fL 80 – 93 fL
MCH 29.8 pg 27 – 31 pg
MCHC 34.5 g/dL 31.9 - 36
Differential count 0.4/0.4/71.7/21.4/6.1 0-4/0-1/51-67/25-33/2-5
%
Ureum 40.5 mg/dl 7.8 – 20.23 mg/dL
Creatinine 1.59 mg/dl 0.8 – 1.3 mg/dL
Albumin 4.03 g/dL 3.5-5.2 g/dL
RBG 141 mg/dl <200
Parameter Result Normal Value
Hs Troponin 3173 ng/L <11.8
PTT 10.8 second 9.4 – 11.3
aPTT 20.8 second 24.6 – 30.6
INR 1.04 <1.5
Na 147 mmol/L 136-145
K 4.04 mmol/L 3.5-5.1
Cl 112 mmol/L 98-107

12. PARAMETER RESULT REFF
pH 7.55 7.35 – 7.45
pCO2 25.1 35 – 45
pO2 115 80 – 100
Bicarbonate (HCO3) 22.1 21 – 28
Base Excess -0.5 (-)3 – (+)3
SaO2 99.1% > 95
Uncompensated respiratory alkalosis
Blood Gas Analysis at RSSA, February 09th 2024 (06.45 PM) on NC 3lpm

13. TIMI risk score
TIMI Score
4/7

14. GRACE Score
107

16. CRUSADE
Score 39

17. Assessment Planning Diagnosis & Therapy
1. NSTEMI Killip I Very High Risk Criteria TIMI
4/7 GRACE 107 CRUSADE 39 pro invasive
Strategy
2. Symptomatic bradycardia dt TAVB with
unstable hemodynamic dt susp. CAD dd
degenerative pro TPM installation
3. HF st. C FC III dt HHD, susp. CAD
4. AKI st. I dd aCKD
5. Menopause
6. Obesity class I
Planning Diagnosis
ECG/24hours, Echocardiography full study, serial cardiac enzyme, FBG/2hPPBG,
HbA1c, Lipid profile, Uric Acid, RFT evaluation
Consult to EP division
Planning Therapy
Pro TPM installation + Invasive Strategy
O2 NC 3-4 lpm
Bedrest
Total fluid 1800-2000 cc/24 hours
Target equal fluid balance
IVFD NaCl 0.9% 1000 cc/24 hours
Oral intake 800-1000 cc/24 hours
Heart diet II 1800 kcal/day
Drip Dopamine 5-20 mcg/kgBW/min (5)
PO
Atorvastatin 0-0-20mg
Bisoprolol (postponed)
Captopril 3x25mg
Laxadine 0-0-C1
Diazepam 0-0-2mg
Planning Monitoring
S, VS, UOP, ECG
Transferred to the Cathlab pro TPM installation
Admitted to CVCU

18. TPM
February 09th 2024

19. TPM Installation (February 09th 2024)

20. TPM Report at RSSA
(February 09th 2024)
• TPM Lead at RV apex
• Setting 80-3-3

21. DCA
Ny. Khiptiyah
11606790

27. Angiography
• LM: Normal
• LAD: Stenosis: 20% at distal LAD
• LCx: Normal
• RC : Strenosis 20% at the proximal RCA
• Conclusion: Minor CAD
Diagnostic post-cateter
• Minor CAD
Recommendation
• Optimal medicamentosa
• Control risk factors (HT, obesity)

28. Assessment Planning Diagnosis & Therapy
1. Symptomatic bradycardia dt TAVB with
unstable hemodynamic dt degenerative post
TPM 80-3-3
2. HF st. C FC III dt HHD, susp. CAD
3. CAD minor Disease
4. AKI st. I dd aCKD
5. Menopause
6. Obesity class I
Planning Diagnosis
ECG/24hours, Echocardiography full study, serial cardiac enzyme, FBG/2hPPBG,
HbA1c, Lipid profile, Uric Acid, RFT evaluation
Consult to EP division
Planning Therapy
TPM 80-3-3
O2 NC 3-4 lpm
Bedrest
Total fluid 1800-2000 cc/24 hours
Target equal fluid balance
IVFD NaCl 0.9% 1000 cc/24 hours
Oral intake 800-1000 cc/24 hours
Heart diet II 1800 kcal/day
Drip Dopamine 5-20 mcg/kgBW/min (5)
PO
Atorvastatin 0-0-20mg
Bisoprolol (postponed)
Captopril 3x25mg
Laxadine 0-0-C1
Diazepam 0-0-2mg
Planning Monitoring
S, VS, UOP, ECG
Transferred to the Cathlab pro TPM installation
Admitted to CVCU

29. Female 68 y.o.
Uncontrolled HT
Menopause
Obesity
Dizziness, dyspnea, chest discomfort,
cold sweating, body weakness,
followed by near syncope while she
was doing mild to moderate activities.
These complaints were persisted
even at rest, so her family brought
her to ER PACCE clinic
The symptoms still persisted.
ECG showed TAVB, didn’t
response with medication, she
was suggested to be referred to
RSSA
Arrived at RSSA, ECG: TAVB,
20-30 bpm, with couplet PVC
episode.The patient was sent to
the Cathlab for TPM installation,
then transferred to CVCU for
further management
Timeline and Natural History
RISK FACTORS 09/02/2024
2 weeks ago
09/02/2024 11.00 AM
ER RSSA 09/02/2024
06.15 PM
ER PACCE clinic

30. BP 160/80 mmHg HR 80 bpm pacing
rhythm
RR 24 tpm SpO2 99% on NC 3-4
lpm
Appeared moderately ill GCS 456 UOP: 1100cc/7 hours
Head Pale conjunctiva (-) Icteric (-)
Neck JVP R+1 cm H2O
Thorax: Cor: Ictus cordis palpable at ICS V 1 cm lat MCL sin, heaves (-), thrill (-),
LHM at apex, RHM at sternal line. Heart sound S1-S2 normal regular,
murmur (+), Pansistolik murmur 4/6 SIC 5 mid clavicula line
Lung: Symmetric Rh - - Wh - -
- - - -
- - - -
Abdomen Soepel, Hepar and lien unpalpable, Hepatojugular reflux (-)
Bowel sounds normal, bruits (-)
Extremities Edema warm acral +/+
- -
- -
Physical Examination at CVCU

31. ECG at CVCU 10/02/2024 (On TPM 80-3-3)
Pacing Rhythm, 80 bpm, LBBB with superior axis
Conclusion: Appropriate RV Apex Pacing

32. 09/02/2024
Laboratory Findings at CVCU
Parameter Result Normal Value
Total Cholesterol 215 mg/dL <200
Triglyceride 131 mg/dL <150
HDL 42 mg/dL >60
LDL 140 mg/dL <100
HbA1C 6.2 % <6.0
FBG 98 mg/dL 74-106
Uric Acid 8.7 mg/dL 2.4-5.7
hs Trop I 2129 ng/L <11.8

33. ECHOCARDIOGRAPHY at CVCU
February 10th 2024

34. Hemodynamic Echocardiography without support
Objective: Echocardiography
Parasternal long-axis view Parasternal long-axis view with color

35. Hemodynamic Echocardiography without support
Objective: Echocardiography
Parasternal short-axis view – Basal Parasternal short-axis view – Mid
11

36. Objective: Echocardiography
Parasternal short-axis view – Apex
14
Hemodynamic Echocardiography without support
Parasternal short-axis view – Great Artery

37. Objective: Echocardiography
Apical 4 chamber view
16
Hemodynamic Echocardiography without support

38. Objective: Echocardiography
A5C view
17
Hemodynamic Echocardiography without support

39. Objective: Echocardiography
18
Hemodynamic Echocardiography without support
Apical 2 chamber view plain and color

40. Objective: Echocardiography
18
Hemodynamic Echocardiography without support
Apical 3 chamber view plain and color

41. Parameters Value
ECG Pacing Rhythm, HR 80 bpm regular
Dimension RA and RV normal, LA dilated, Concentric LVH
Systolic LV Function LVEF 58% by Teich, 56% by Simpson (LViDd 4.6, RWT 0.58, LVMI 145)
Diastolic LV Function Diastolic Dysfunction grade I (E/A 0.8)
Systolic RV Function Normal (TAPSE 1.7 cm)
Valve Mitral Valve: MS (-), MR severe (MR VC 0.8 cm)
Tricuspid Valve: TS (-), TR mild (TR Vmax 2.7 m/s, maxPG 29 mmHg) with intermediate probability of PH
Aortic Valve: 3 Cusps, AS (-), AR (-)
Pulmonic Valve: PS (-) PR mild
Segmental Analysis Global normokinetic
Others CO/SV 4.6 L/min / 57 ml
CI 2.8 L/min/m2
SVR 1739 dynes/sec/cm-5
IVC/PCWP 1.3 – 1.9 cm/14 mmHg
Other findings Pericardial effusion (-), SEC (-), Thrombus (-), Vegetations (-), pleural effusion (-) lead TPM (+) RV apex
Echocardiography at CVCU RSSA without support

42. Re-Assessment Planning Diagnosis & Therapy
1. Symptomatic bradycardia dt TAVB ec
degenerative on TPM 80-3-3
2. HFpEF st. C FC III dt HHD dd VHD (EF 56% by
Simpson)
3. CAD Minor Disease
4. AKI st. I dd aCKD
5. Dyslipidemia
6. Menopause
7. Obesity class I
Planning Diagnosis
ECG/24hours (on/off TPM), Echocardiography full study, RFT
evaluation, Consult to EP division
Planning Therapy
O2 NC 3-4 lpm
Bedrest, right leg immobilitation
Total fluid 1800-2000 cc/24 hours
Target equal fluid balance
IVFD NaCl 0.9% 1000 cc/24 hours
Oral intake 800-1000 cc/24 hours
Heart diet II 1800 kcal/day
Drip Dopamine 5-20 mcg/kgBW/min  Stop
PO
Atorvastatin 0-0-20mg
Bisoprolol (postponed)
Captopril 3x25mg
Laxadine 0-0-C1
Diazepam 0-0-2mg
Planning Monitoring
S, VS, UOP, ECG

43. CUE AND CLUE PL Idx PDx PTx PMo
Mrs. K/68 yo/11606790
Subjective
Dizziness, dyspnea, chest discomfort, cold
sweating, body weakness, followed by near
syncope at 05.00 AM 09/02/2024.
History with the same complaints about 2 weeks
ago ago
Risk factors: Uncontrolled HT, Menopause,
Obesity
Objective
A/ Clear, patent
B/ Reguler, spontan, RR 22x/m, SpO2 98% on NC
3-4 lpm, Rh -/- Wh -/-
C/ TD 158/100 mmHg; HR 20-30x/min on
Dopamine 5 mcg/kgBW/min
D/ GCS 456
E/ Warm acral, edema -/-
F/ UOP: 1700 cc/7h
ECG: TAVB with junctional rhythm, PVC couplet
episode + complete RBBB
CXR: Cardiomegaly (CTR 76%)
Echo: LA dilated, concentric LVH, LV diastolic
dysfunction grade I, EF 56% by Simpson, MR
severe, TR mild w/ intermediate prob of PH
Lab :
Na/K/Cl: 147/4.04/112
DL: 13.2/15,040/243,000
Ur/Cr: 40.5/1.59
hs Trop I: 3173 --> 2129
1. Dizziness, dyspnea,
chest discomfort, cold
sweating, body
weakness, followed by
near syncope
2. Risk factors: Female 68
y.o., Uncontrolled HT,
Menopause, Obesity
3. ECG: TAVB
Symptomatic bradycardia
with TAVB
1.1 Susp. CAD
1.2 Degenerative
ECG serial • Drip Dopamine 5–20 mcg/kgBW/min
• TPM installation
Consult to EP Division
S, VS, ECG

44. CUE AND CLUE PL Idx PDx PTx PMo
Mrs. K/68 yo/11606790
Subjective
History of DOE while doing mild-moderate
activities since the last 1 year.
Risk factors: Uncontrolled HT, Menopause,
Obesity
Objective
A/ Clear, patent
B/ Reguler, spontan, RR 22x/m, SpO2 98% on NC
3-4 lpm, Rh -/- Wh -/-
C/ TD 158/100 mmHg; HR 20-30x/min on
Dopamine 5 mcg/kgBW/min
D/ GCS 456
E/ Warm acral, edema -/-
F/ UOP: 1700 cc/7h
ECG: TAVB with junctional rhythm, PVC couplet
episode + complete RBBB
CXR: Cardiomegaly (CTR 76%)
Echo: LA dilated, concentric LVH, LV diastolic
dysfunction grade I, EF 56% by Simpson, MR
severe, TR mild w/ intermediate prob of PH
Lab :
hs Trop I: 3173 --> 2129
1. DOE(+)
2. Risk factor
(uncontrolled HT,
menopause, obesity)
3. CXR: cardiomegaly
4. Echo: concentric LVH,
diastolic dysfunction,
MR severe
HFpEF st. C FC III dt HHD dd
VHD (EF 56% by Simpson)
Echo Full Study • Captopril 3x25mg
• Bisoprolol (postponed)
Educate the patient and family to adherence
to treatment and controlled routinely
Educate to healthy diet avoiding excessive
salt intake (>5g/day)
S, VS, UOP,
ECG

45. CUE AND CLUE PL Idx PDx PTx PMo
Mrs. K/68 yo/11606790
Subjective
Dizziness with chest discomfort also cold
sweating. Actually chest discomfort since 2
weeks ago while doing mild to moderate
activities
Risk Factors:
Uncontrolled HT, Menopause, Obesity
Objective
A/ Clear, patent
B/ Reguler, spontan, RR 22x/m, SpO2 98%
on NC 3-4 lpm, Rh -/- Wh -/-
C/ TD 158/100 mmHg; HR 30-40x/min on
Dopamine 5 mcg/kgBW/min
D/ GCS 456
E/ Warm acral, edema -/-
F/ UOP: 1700 cc/7h
ECG: TAVB with junctional rhythm, PVC
couplet episode + complete RBBB
CXR: Cardiomegaly (CTR 76%)
Echo: LA dilated, concentric LVH, LV
diastolic dysfunction grade I, EF 56% by
Simpson, MR severe, TR mild w/
intermediate prob of PH
1. Chest discomfort
2. Dyspnea
3. CXR: Cardiomegaly
4. Dyslipidemia
5. Echo: concentric
LVH, diastolic
dysfunction
NSTEMI Killip I
Very High Risk
Criteria TIMI 4/7
GRACE 107
CRUSADE 39 pro
invasive Strategy
 CAD Minor
Disease
- PTx:
Atorvastatin 0-0-20 mg
Educate patient and family after
discharge for:
- Low lipid diet (target LDL
<55mg/dl or reduction >50%
baseline)
S, VS, ECG

46. Condition this morning
Subjective:
Dizziness, chest discomfort, dyspnea were decreased
Objective:
GCS 456
BP 128/66 mmHg
HR 70 bpm on TPM 70-3-3
RR 18-20 x/min
SpO2 99% on NC 4 lpm
UOP 2500 cc/24 hours
Fluid Balance 1000 cc/24 hours

47. ECG at CVCU 12/02/2024 (On TPM 80-3-3)
Pacing Rhythm, 80 bpm, LBBB with superior axis
Conclusion: Appropriate RV Apex Pacing

48. ECG at CVCU 12/02/2024 (On Standby TPM 40-3-3)
TAVB, atrial rate 90 bpm, ventricular rate 40 bpm, FA N, HA CCWR, QRS dur 120 ms, ST changes (-)
Conclusion: TAVB with dependent pacing rhythm 40 tpm

50. BRADYCARDIA