79 YEARS OLD MAN WITH ANTEROSEPTAL OLD MYOCARD INFARCTION

Lecturer : Prof. DR. dr. Moch. Fathoni, Sp. JP(K), FIHA

By: Amelia Kartika Widowati Anastasia Fani Chrisanti Nurotus Saniyah Dewi Ayu Astari P.

Patient Identity
Name Age Gender Religion Occupation Address Medical Record Hospitalized : Mr. S : 79 years old : Male : Moslem :: Manahan Banjarsari : 01189086 : April 9th 2013

CHIEF COMPLAINT

Shortness of breath

History of Present illness

Approximately three days before hospitalized, patient felt the shortness of breath. It appeared on activity and decreased by rest. Patient sleeps with a pillow. Cold sweating (-), awakened at night because of breathless (+), breathless caused by changing position (-), fainting (-), bloody coughing (-), easily tired (-). About a week ago patient complained an intermitent epigastric pain. Nausea (+), vomitting (-)

History of past illness

History of heart disease History of hypertension years History of stroke History of diabetes mellitus History of hospitalization History of Asthma History of allergy : (-) : (+) since 10 : (-) : (-) : (-) : (-) : (-)

EATING BEHAVIOR

2-3 times a day, consumed rice, vegetables, tahu-tempe, occassionally eggs ang meat.

LIFE STYLE

Regularly cycling. Didnt smoke. Didnt drink alcohol.

SOSIOECONOMIC

He is an unemployment with 4 children and 5 grandchildren. His wife was dead 2 years ago. He lives with his son. His son works as a labour.

PHYSICAL EXAMINATION
General Condition: Compos Mentis, moderate illness Vital Signs: BP = 135/80 mmHg HR = 87 bpm, reguler, normal intensity RR = 20 times/minute Temperature = 36,2C (axillar) Nutritional status = normoweight

 Eyes

: Pale conjunctiva (-/-), Icteric conjunctiva (-/-) Neck : JVP wasnt increased, No enlargement of Lymphnode Thorax : normochest, symmetrical, intercostal retractions (-)

 Heart : - Inspection : Ictus cordis was seen at SIC VI Linea Axilaris Anterior Sinistra - Palpation : Ictus cordis wast - Percussion : 1. Upper limit of the right heart: SIC II, linea parasternalis dextra 2. Bottom right cardiac border: SIC IV, linea parasternalis dextra 3. Upper left cardiac border: SIC II, linea parasternalis sinistra 4. Lower left cardiac border: SIC VI, linea axilaris anterior sinistra Impression: cardiac border was extend caudolateral - Auscultation: 1. Heart Rate: 87 x/ min, regular 2. Intensity of the Heart sound I-II are normal, regular, murmurs (-), Gallop (+)

Lungs : Front Inspection : static and dynamic symmetric Palpation : fumbling fremitus for right = left Percussion : sonor/ sonor Auscultation : Basic vesicular sounds (+/+), Fine crackles (-/-), rales (+/+) in lower third of the lungs , wheezing (-/-) Back Inspection : static and dynamic symmetric Palpation : fumbling fremitus for right = left Percussion : sonor / sonor Auscultation: basic vesicular sound (+/+), fine crackles (-/-), rales (+/+) in lower third of the lungs , wheezing (-/-)

 Abdominal : - Inspection : abdominal wall = chest wall - Auscultation : bowel peristaltic (+) normal - Percussion : tympanic - Palpation : outgoing, tenderness (-), liver and spleen not palpable, epigastric pain (+) Back : Kyphosis (-), lordosis (-), scoliosis (-) Extremity : - Above : pitting edema (-/-), cold acral (-/-), wound (-/-), clubbing finger (-/-), spoon nail (-/-) - Under : pitting edema (-/-), cold acral (-/-), wound (-/-), clubbing finger (-/-), spoon nail (-/-)

09/4/2013 Hb HCT RBC WBC PLT GDS Ureum Creatinin Natrium Kalium Chlorida CKMB Troponin 11,9 36 3,72 5,0 217 100 81 1,2 138 4,2 113 7,8 0,02

UNIT g/dl % 106/l 103/l 103 /l mg/dL mg/dL mg/dL

mmol/L
mmol/L mmol/L ng/l ug/l

Sinus Rhythm, HR 82 bpm Left Axis Deviation Left Atrial Enlargement T inverted in lead I, aVL, V5, V6

KATZ- WACHTEL PHENOMENON

LVH/ LBBB in precordial lead & LAD Tall R in all precordial leads & RAD High/deep amplitude of QRS in V2-V4
-

LVH & P pulmonal in the limb lead

- AF rapid ventricular response HR 160x/mnt - Poor R wave progression - Biventricular enlargement

Simetric Bronchovascular system is normal Costophrenic angle is blunt CTR >50 % Calsification of aortic knob Fibroinfiltrat with multiple cavities in right lung Cephalitation in both of lungs
CONCLUSION Cardiomegaly with aorto schlerosis Early suspect of oedem pulmo Suspect of TB Bilateral efussion of pleura

 Anatomic : anteroseptal OMI Functional : Decompensated cordis NYHA IV Etiology : hipertension heart disease Comorbid : dyspepsia

Half-sitting bedrest O2 3lt/mnt Infus RL 10 dpm Furosemid Inj 20 mg/8 hours Ranitidin Inj. 50 mg/12 hours Spironolakton 25 mg 1-0-0 ISDN 3 x 5 mg Captopril 3x12,5 mg Simvastatin 20 mg 0-0-1 Alprazolam 0,5 mg 0-0-1 Aspilet 80 mg 0-1-0 Antacyd syr 3 x CI

 Consult pulmonologist for pleural effusion Echocardiography

PROGNOSIS
Ad Vitam : dubia ad bonam Ad Sanam : dubia ad malam Ad funsionam : dubia ad malam