Clinical Review:

Chest Pain

Dr. Zsa Zsa Maranani

IDENTITY

Name : Mr. RFL

DOB : September 06th, 1976/ 39 years old
Gender : Male
Race : Batak

TIMELINE
2016)

KKC

(March

26th,

12.41 : He came to ER KKC by himself, could walk

steadily without an assist (Alert condition).
12.42: He complained chest pain since last night,
Vital Sign Blood Pressure 131/81 mmHg, Pulse 80
bpm, Temp 36.9C, RR 22x/min, SpO2 98%
12:54: He complained chest pain since last night, the pain could
be pointed with one finger at upper right chest area, he felt pain
either in activity or no activity, pain came and disappeared
suddenly, no radiated pain, no more pain with breathing
movement, pain was more reduced if compared with overnight, no
short of breathing, no heartburn, no nausea or vomiting, no
palpitation, he admitted that the pain was different kind of pain
when compared with chest pain while he got hearts problem
before, he also confessed that he was in stress condition, no drugs
taken routinely, had stopped taking hearts medications (he said
that stopped for 1 year by dr.Ojongs instruction) ECG done, and
the result: Normal synus rhythm 61bpm

Physical
Examination
Eye : No Anemic and no scleral Icteric, pupil
isochor 3mm/3mm, light reflection+/+
Oropharynx : no pharing hiperemis (-), Oral
candidiasis (-)
Neck : no enlargement of neck lymph node, no
elevated JVP
Lungs : vesicular sound +/+, Rh -/-, Wh -/ Cardio : S1-2 single,normal, reguler, no murmur ,
no gallop
Abdomen : soft, BS (+), tympani, H/L unpalpable,
no mass palpable
Extremity : warm, edema-/-, ikterik-/-, sianosis-/Chest: no retraction, no hematoma, no wound,

Treatment
Observation in ER KKC for a while
Miniaspi 80mg OD
Suggest to control again in Tuesday or
Wednesday to dr.Ojong (while the drugs
was given to him, nurse lala gave him
advice to stop smoking still smoking?
Even in KMS recorded already stopped
smoking on several previous
examination)

POST MORTEM

Estimated the time of death 16.30 (in Klinik Chandra)

No wound on his body
Bruised corpse was found at his mandible, spread to
shoulder and back (examined at 19.00 in KKC)
Reported by his child: after took 1 drug from KKC, he
complained of stomache and vomited. Several minutes later,
he got seizure and still unconscious after seizure.
Laboratory result (19.23 in KKC):
WBC 8.3/ RBC 1.95/ Hb 5.8/ Ht 17.0/ PLT 389
Na 143/ K 10.1/ Cl 106
Trop T <50ng/L
CKMB: 1.81 ng/mL
SGOT 29/ SGPT 49/ Gamma GT 80

Previous Histories

05-03-2013: He was referred to Premiere Jatinegara Hospital

with Medevac
02-04-2013: He got back from Medevac, post PCI on March
2013, had routinely drugs as advised (Ascardia 80mg OD,
Plavix 75mg OD, Lipitor 40mg ON)
09-04-2013: He had examined with dr.Ojong dan got
permission for back ti work. Suggest treatment bisoprolol 5
mg, ramipril 5 mg, ascardia, plavix, lipitor 20 mg.
16-07-2013: He had examined with dr.Ojong, and got fatty
liver from USG. Suggest treatment bisoprolol 2.5 mg, ascardia,
plavix
15-03-2014: he got treadmill test, the result was normal,
suggest treatment stop plavix, continue ascardia and
bisoprolol
04-03-2015: last took the drug regularly (miniaspi and
ramipril), patients taking the drug for three months
25-04-2015: he got treadmill test with dr.Ojong, the result was

Thank You