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Case Report
Coronary Artery Disease
Supervisor :
dr. H. Bambang Rudy Utantio, SP. JP. FIHA
By :Valentinne Yuasita
04.70.0234
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Identity
Name : Mr. Dalim
Age : 52 years old
Sex : Male
Occupation : Security (Pension)
Address : Damarsi - Buduran
Marital status : Married
Religion : MoeslemAddmited to hospital : 27 June 2010
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Major Complain
Short of Breath
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Disease History Now
Patient come to ER with complain short of breath. He fell
it after he vomiting last morning. He vomit food and fluidwithout blood. He feel discomfort with his stomach. Buthe didnt have gastric pain history. He didnt eat late.
Actually he fell discomfort with his breath since 7 yearsago. But become worst in six months later. He feels betterwhen sleep at home if he use 3 more pillow, less than thathe feel discomfort with his breath.
He often wake up at night because of his shortness ofbreath. It push him to looking for fresh air, and usually hefeel better after that
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He said that his short breath also come who he walktoo long and heavy activity like work at garden.
His short breath doesnt Induced with dust or coldair.
Perceived shortness no wheezing or grok-grok(ronki)
Hes got chest pain too. It feels in his left chest likeburning and creeping to his back. He cant showingspesificly which is the pain come after he feeldisappointed or angry. And he feel chest pain about
5-10 minutes. This chest pain become better after hisemotion was cooling down.
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Formerly Disease History
Asthma denied TB history denied Allergy history denied DM denied HT (+) : Since 7 years ago, he usually consumt
captopril 25 mg 3 x 1 and furosemide 40mg1 x 1, higher sistole 180.
Decompensatio cordis (+)Patient know the heart become bigger since 6 month ago.
Family Disease
HT (+) DM (-) PsycosocietyEducation : Senior high schoolOccuption : Security (Pension)Marital status : Married, 30 years there children
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Habitual :
Alkohol (-) Coffe (+) he drink coffe over than 2 glass a day
Heavy smookers, he smoke continuously 15
years and he stopped 7 years ago (he smokeover than 3 pack a day).
Exercise (-)
He like salty food
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Nutrition Anamnesa
Food consumption : 3 times dailyAmount : medium
Content of
Carbohydrate : mediumProtein : medium
Fat : large
Fruit : lowVegetable : medium
Weight : decrease
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Physical Examination
General condition : Moderate
Consiousness : Composmentis
Blood pressure : 140/100 mmHg, layposition right arm
Pulse pressure : 98 x/menit, reguler and
strong RR : 26 x.menit
Temperature : 36 C
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Head and Neck
Eyes : Conjuntiva anemis (-/-)
Sclera Icterus (+/+)
Ears : Normal
Nose : Dyspneu (+)
Neck : Vena jugularis distension (-)
Trachea in middle
Thyroid hipertrophy (-)
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Thorax
Lung
Inspection : Simetry shape
Simetry movement
Palpation : Simetry movement
Percussion : Simetry fremitus tactilePain (-)
Auscultation :
Vesiculer : Knock sound (+)Ronchi : (+/+) in the whole auscultation
area of lung (wet ronchi)
Wheezing : (-/-)
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COR Inspection : Ictus cordis (-)
heart pulsation (-) Palpation : Ictus (-)Thrill (-)
Percussion :Sinistra :
Ics II dan III 3 cm PSL SinistraIcs IV 3 cm PSL sinistraIcs V 1 cm MCL SinistraIcs VI 1 cm medial Axilla anterior line sinistraDextra :
Ics II dan III 1 cm PSL DextraIcs IV 2 cm PSL DextraIcs V 3 cm PSL DextraIcs VI 3 cm PSL Dextra
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Auscultation
S1S
2tunggal reguler
S3S
4(-)
Opening snap : (-)
Systolic ejectionclick : (-)
Friction rub : (-)
Mur mur : (+)
Fase : SistolicLocation : 3 Ostia
Aorta Valva
Mitral Valva
Trikuspid Valva
Intensity : III / VIPitch : low
Quality : Rumbling
Moving : moving
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ABDOMEN
Inspection : normal
Palpation : Tonus & turgor (N) Spleen and kidney unpalpable Liver palpable 1 cm under arcus costae Epigastric pain (-)
Percussion :Tympanic sound (+)Auscultation : Peristaltic movement (+)Inguinal Genital Anus (normal)
EXTRIMITAS
Accral warm superior + / +
inferior + / +
Edem superior - / -
inferior - / -
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Thorax PA
Cardiomegali
Like Boot Shoes
CTR : 14 + 7 x 100 = 75%28
Pleura Odema
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CONCLUSION
Rate : 1500 / 15 = 100 x / menit
Rhytm : Sinus, reguler
Axis : LAD
Hipertrophy : Left Ventrikel HipertrophyIschemia : Lateral wall iscemia myocard
Infark : -
Misscellaneus : -
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Laboratory
27 June 2010
Test Result Flag Reference Range (limit 3)
WBC 8,6 K/ulLym 1,7Mid 0,7
Gran 6,3RBC 4,55 M/ulHGB 13,2 g/dlHCT 39,9 %MCV 87,6 fl
MCH 29,0MCHC 33,1 9/dlRDW 14,0 %PLT 210 k/ulMPV 9,4 FL
NormalNormalNormal
NormalNormalNormalNormalNormal
NormalNormalNormalNormalNormal
4,1 10,9 K/ul0,6 4,10,0 1,8
2,0 784,20 6,30 M/ul12,0 18,0 g / dl37,0 51,0 0 %80,0 97,0 fl
26,0 32,0 pq31,0 36,0 9 / dl11,5 14,5 %140 440 K/ul0,0 99,8 FL
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Test Metod Result Reference Range
GDA
BUN
Creatinin
Natrium
KaliumChlorida
SGOT
SGPT
Kinetik UV
Jaffe and
Ise
IseIse
Ast IFCC
Ast IFCC
135
14,5
1,3
144
3,8111
385
294
< 140 mg / dl
6 23 mg / dl
0,7 1,2 mg / dl
137 145 mmol / L
3,6 5,0 mmol / L98 107 mmol / L
< 40 U / L
< 41 U / L
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RESUME
MR Dalim 52 years old come to ER because of his short
breath PND (+), Orthopneu (+) , DOE (+), Chest Pain (+)It feels like burning and creeping to his back .It becomeworst after he feel dissapointed or angry .And he feelchest Pain about 5 10 Minutes. The chest pain becomebetter after his emotion was cooling down.
Medical history:HT(+), DC (+)Physical examination :General condition : moderateConsiousness : composmentisBlood Pressure : 140 / 100 mmHg, lay Position
right armPulse Pressure : 98x / menit , reguler and strongRR : 26x / menitTemperatur : 36oc
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ThoraxLung :Ronchi (+/+) in the whole auscultation are of lung (wet ronchi)
COR Inspection : Ictus cordis (-)
heart pulsation (-) Palpation : Ictus (-)
Thrill (-)
Percussion :SinistraIcs II dan III 3 cm PSL SinistraIcs IV 3 cm psl sinistraIcs V MCL SinistraIcs VI 1 cm medial Axilla anterior line sinistra
DextraIcs II dan III 1 cm PSL DextraIcs IV 2 cm PSL DextraIcs V 3 cm PSL DextraIcs VI 3 cm PSL Dextra
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Auscultation
S1S2 tunggal reg
S3S
4(-)
Opening snap : (-)
Systolic ejectionclick : (-)
Friction rub : (-)
Mur mur : (+)
Fase : SistolicLocation : 3 Ostia
Aorta Valva
Mitral Valva
Trikuspid ValvaIntensity : III / VI
Quality : Rumbling
Moving : moving
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Abdomen :Liver Paipable 1 cm Under arcus
costaeExtrimitas : NormalPhoto Thorax : - Cardiomegali
- Odem pleura
Laboratory :
SGOT 385
SGPT 294 Chlorida 111
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Diagnosa
CardiologyI. Dx of etiology : HT stage I JNC VII
Dx of Anatomy : - cardiomegali
- left Ventrikel hiperthrofi
Dx of Fisiologi : DC Nyha FC III
II.Dx of etiologi : CAD
Dx of Anatomy : lateral wall Ischemia myocard
Dx of Fisiologi : DC Nyha FC III
III. Non cardiology
1. Hiperchloridemia2. Hepatomegali
3. Dyspepsia Syndrome
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Planing Diagnosis
USG Abdomen
Profil Lipid
Bilirubin Direct Bilirubin Total
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Therapy
Non farmacology :
Diit low sodium Diit low fat O
22 lpm nasal
Semi fowler position Urinary cateter
Farma cology : Inf PZ life line Furosemide 40 mg 1 0 0 Bisoprolol 5 mg 1 x 1 Spironolakton 25 mg 1 x 1
Aspilat 100mg 1 x 1 Simvastatin 20mg 0 - 0 - 1 Inj.Ranitidin 2 x 1 Amp Inj. Ondancentron 3 x 1 Amp
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PROGNOSE
DUBOIS AD MALAM