A 55 Years Man With Chest Pain

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Transcript of A 55 Years Man With Chest Pain

Case Presentation

A 55 Years Man with Dyspnea

By:

Valentina Lakhsmi

G99141003

Advisor : Prof. Dr. dr. Mochammad Fathoni, SpJP(K), FIHA, FAsCC, FAPSC

Patient Identity• Name : Mr. SYD• Age : 55 years old• Sex : Male• Address : Wonogiri• Job : salesman• Date of entry : 22 July 2014• Date of inspection : 23 July 2014• Medical Record Number: 00 75 43 20

ANAMNESIS

History of Patient Ilness

History of patient disease

Physical Examination(22/07/2014)

Anamnesis Px Fisik Px Penunjang Resume DiagnosisPx Fisik

Neck: JVP elevated

Cor:I: Ictus Cordis was not visibleP: Ictus cordis was not palpableP: impression of cor’s border was not dilatedA: heart sound I-II normal intensity, regular, murmur (-)Abdomen: liver and

spleen were not palpable, bowel sound (+) normal, ballotement (-)

oedem (-/-)Cold extremities (-/-)

Hemiparese dx

Eye: pale conjunctiva (-/-), icteric sclera (-/-)

Pulmo: vesicular breath sound (+/+), rales (+/+), crackles (+/+), wheezing (-/-)

oedem (+/+)Cold extremities (-/-)

Hemiparese dx

Emergency Room 22/07/2014 (11.47 am)

ER

ECGICVCU(23/07/2014; 05.00 a.m)

ICVCU (23/07/2014)

Laboratory Findings(22/07/2014)

• HB : 16,6 GDS : 274

• HCT : 47 SGOT : 62

• AL : 11,5 SGPT : 150

• AT : 305 Creatinine : 2,4

• AE : 5,51 Ureum : 104

• MCV : 85,6 Na : 138

• MCH : 30,1 K : 5,2

• MCHC : 35,2 Cl : 109

• RDW : 12,5 HbsAg : nonreactive

• MPV : 8,7 Albumin : 3,8

• PDW : 16

Laboratory Findings(22/07/2014)

• BGA• pH : 7.316• BE : -7.9• pCO2 : 33.8• pO2 : 118.5• H2CO3 : 18.0• Total CO2 : 14.0• SaO2 : 98.0

• Uncompensated metabolic acidocis

Radiology(23/07/2014)

CTR >50%cardiomegaly with pulmonal oedema

Echocardiography(03/05/2012)

Excentric LVH with restrictive diastolic disturbanceAbnormality of segmental wall motion (EF : 25%)MR and TR mild

Diagnose

Therapy (22/07/2014)

PLAN• Echocardiography

• Complete the laboratory tests for DM

• Consultation with neurologist

• Cranial CT scan

• Consultation with internist

Physical Examination(23/07/2014)

Anamnesis Px Fisik Px Penunjang Resume DiagnosisPx Fisik

Neck: JVP elevated

Cor:I: Ictus Cordis was not visibleP: Ictus cordis was not palpableP: impression of cor’s border was not dilatedA: heart sound I-II normal intensity, regular, murmur (-)Abdomen: liver and

spleen were not palpable, bowel sound (+) normal, ballotement (-)

oedem (-/-)Cold extremities (-/-)

Hemiparese dx

Eye: pale conjunctiva (-/-), icteric sclera (-/-)

Pulmo: vesicular breath sound (+/+), rales (+/+), crackles (+/+), wheezing (-/-)

oedem (+/+)Cold extremities (-/-)

Hemiparese dx

Laboratory Findings(23/07/2014)

• HbA1c : 8,1• GDP : 187• GD2PP : 297• Creatinine : 2,4• Ureum : 90• Uric acid : 11,7• Total Chol : 252• LDL : 194• HDL : 32• Trigliserida : 169

Neurologic Findings ( 23/07/2014 )

Neurologic Findings ( 23/07/2014 )

Therapy (17/07/2014)

PLAN• Echocardiography

• Complete the laboratory tests

• Cranial CT scan

Case analysis

Case analysis

Case analysis : complication of MI

Case analysis

Case analysis

Case analysis