Letak Sungsang

Referat
Isma Resti Pratiwi, S. Ked

Departemen Obstetri dan Ginekologi

RSUD Abdul Aziz Singkawang
2017
Mr. YM, a Male, 51
Years Old
Chief Complaint: Palpitation
Summary of Database

Male, 51 y.o. came with palpitations felt since 3

hours before administered.
He also felt a chest pain 1 day before, the chest
pain is typical for cardiac chest pain, and the
symptom persists until he came to the
Emergency Department
He had history of the same complaint before,
had been through DCA procedure -- found 3-
vessel-disease and had been undergone the PCI
procedures second times a year ago,
Past Medical History

History of well controlled hypertension since 5

years ago
No history of diabetes or asthma
Physical Examination (5/2/17)
BP = 110/80mmHg PR : 167 tpm, regular, pulsus RR = 34 tpm, 97% T ax 36,5C
defisit (-)

General appearance looked moderately ill GCS 456 , compos menits

Head Anemic (-/-) Icteric -

Neck JVP 5+2 cmH2O

Thorax Invisible Palpable at Ictus ICS VI MCL S,

Heart RHM SL D, LHM as ictus,
S1 S2 single, mur mur (-), gallop (-)

lung Simetric, SF D = S SS v v Rh - - Wh - -
S S bv bv - - - -
D S bv bv - - - -

Abdomen Convex, Soefl, Hepar : Liver span 12 cm, tenderness point (+) epigastric

Extremities Oedema (-/-)

 Laboratory Findings (5/2/17)

Lab Value

Hb 14,8 13,0 18,0

RBC 5,9 4,0 5,5
WBC 6,1 4,0 10,0

HT 46,3 38,0 51,0

PLT 198 150 450

CKMB 18 <24

GDS 150 >160

ECG Records (5/2/17)
Supraventricular
tachycardya,
133x/minutes
Left Axis Deviation
Pathologic Q in lead II,
III, AVF
Broad, notched R in
V6
Absent R and
prominent S in V1

Conc:
Supraventricular
Tachycardia with
Incomplete Left
Bundle Branch Block
and Inferior OMI
DCA (16/6/2016)

Right dominant
circulation, normal LM
vessel, 95% stenosis
on proximal RCA, 40-
45% stenosis on mid
RCA, CTO on LAD,
patent old stent on
LCx.

The PCI procedure

was done to the
proximal RCA
 Further Examinations

DCA to
Echocardio-
evaluate the Lipid profil
graphy
stent
 Diagnosis
Clinical Diagnosis: Supraventricular Tachycardia
with Unstable Angina

Anatomical Diagnosis Complete Total Occlusion in

LAD, Stenosis in LCx and RCA
and Inferior Infarction

Etiology Diagnosis Atherosclerosis

Planning Therapy

Non Pharmacological Pharmacological

O2 2-4 lpm IVFD NS 500 cc / 24 hour
Natrium restriction Amiodarone 150mg in 10
Bed rest min IV via syringe pump
Refer to Cardiologist (loading) 600mg/24 hour
Pro DCA and PCI IV (maintenance)
Copidogrel 1 x 75mg PO
Aspillet 1 x 80 mg PO
Concor 1 x 2,5mg PO
Atorvastatin 1 x 20mg PO
Prognosis

Quo ad vitam : Dubia ad malam

Quo ad sanactionam : Dubia ad malam
Quo ad Functionam : Dubia ad malam
Thanks!
Any questions ?