CASE REFLECTION

A 48 YEARS OLD WOMAN

WITH LEFT CHEST PAIN
PRESENTED BY:
TASIA DEASTUTI, S.KED
012.096.031

ADVISER :
DR.JACOBUS ALBERT, SP.PD KGEH

SULTAN AGUNG ISLAMIC MEDICAL UNIVERSITY

DR. ADHYATMA TUGUREJO HOSPITAL
SEMARANG
2013
 LIST PROBLEM
Date Active Problem Pasive Problem

2 September 1. Angina Pectoris

1. JAMKESMASNAS
2013 2. Dispepsia Syndrome
 PATIENTS IDENTITY
Name : Ny. R
Age : 48 years old
Sex : Woman
Religion : Moeslem
Occupation : a housewife
Adreess : Kemiri RT 03/X Sumber
Agung Weleri Kendal
Medical Record : 42.71.15
Room : Mawar
Date of income : 26 Agustus 2013
Date of examination : 2 September 2013
Chief Complaint

Chest Pain
 ANAMNESA
PRESENT ILLNESS
Onset : 1 month ago before come to hospital
Cronology : the morning before come to
hospital, suddenly the patient complained left
chest pain , felt heavy on the left chest while
cleaning the house
Location : Chest pain is felt on the left side
and extends to the left shoulder and left back
Quantity : the pain is intermittent, usually the
pain felt about ten minutes and
Quality : the pain is felt heavy on the left chest
 Severity: precipitated by some activity
Modifications Factor : the pain disappears
with rest.
Associated symptoms : the patient also
complaint dizziness, nausea and vomitus since
1 month ago before come to hospital,
continuously every consumption food or drink,
and felt heartburn after vomitus. Patients also
complain of cold sweat came out during a
relapse of her chest pain
The patient had been treated at RS Weleri, but
no improvements to the complaints that
patients come to Tugurejos Hospital
PAST HEALTH HISTORY

History of similar illness: denied

Hypertension History : recognized
Heart Dissease History : denied
Liver disease History : denied
DM History : denied
Gastritis history : recognized
Drug allergic history : denied
Family Health History
History of similar illness: denied
Hypertension History : denied
Heart Dissease History : denied
Liver disease History : denied
DM History : denied
Social Economi History
The patient as a housewife.
Patients treated with the cost of
JAMKESMASNAS
Patients admitted irregular diet every
day.
 Physical Examination
General Status : Look weak
Awareness : compos mentis
Nutrion Status
Weigh :61kg
Heigh: 168 cm
BMI : 21,5 kg/m2
Analyzise : Normoweight
Vital Sign
Blood Pressure : 110/70 mmHg
Heart rate : 64x/minute, regulary, contents and
sufficient voltage
Respirasi : 20 x/minute
temperature : 36,1 C (peraxiller)
 Head : normal
Eyes: normal
Ear : normal
Nose : normal
Mouth : normal
Skin : normal
Throat : normal
CARDIAC
Inspection : Ictus cordis seen at ICS V linea 2 cm med
mid clavicula sinistra
Palpation : Ictus cordis is palpable at ICS linea 2cm
med mid clavicula sinistra , pulsus epigastrium (-), pulsus
parasternal (-), sternal lift (-).
Percussion :
Upper borderline of heart : ICS II linea sternalis
sinistra
Waist borderline of heart : ICS III linea
parasternalis sinistra
Lower right borderline of heart : ICS V linea sternalis
dextra
Lower left borderline of heart : ICS V linea mid clavicula
sinistra 2 cm medial
Interpretation : normal
Chest Examination-Lung

I : Static : normochest , symmetric, retraction

intercostal (-)
Dynamic: up and down hemithorax D / S is
symmetric, retraction intercostal (-)
Pa :Statis: palpation pain (-), symmetric,enlargement
of ICS (-),
Dinamis: up and down hemithorax D / S is
symmetric, enlargement of ICS (-) ,

Stem fremitus D=S

 I: Static : normochest , symmetric, retraction
intercostal (-)

Dynamic: up and down hemithorax D / S is

symmetric, retraction intercostal (-)
Pa :Statis: palpation pain (-),
symmetric,enlargement of ICS (-),
Dinamis: up and down hemithorax D / S is
symmetric, enlargement of ICS (-) ,

Stem fremitus D=S

Pe : D (sonor) / S (sonor )
ABDOMEN
Inspeksi : flat, massa (-)
Auskultation : peristaltic (+), Noise of Gut (+) N
Percution : tymphani
Palpation : sociable (+), press pain on the
epigastrium

Ekstremitas : Cold upper ektremities (-/-), cold

lower ektremitas (-/-) Oedem upper
ektremities (-/-) oedem lower extremities
(-/-)
Blood test - 26th August 2013
PEMERIKSAAN HASIL SATUAN NILAI NORMAL

DARAH RUTIN
Leukosit 9,40 103/uL 3,8-10.6
Eritrosit 4.80 106/uL 4,4-5,9
Hemoglobin 14,40 g/dL 13,2-17,3
Hematokrit 40.40 % 10-52
MCV 84,20 f/L 80-100
MCH 30,00 Pg 26-34
MCHC 35.60 g/dL 32-36
Trombosit 267 103/uL 140-392
RDW 12,70 % 11,5-14,5
Diff Count

Eosinofil absolute 0,20 103/uL 0,045-0,44

Basofil absolute 0,00 103/uL 0-0,2

Netrofil absolute 5,92 103/uL 1,0-6

Limfosit absolute 2,52 103/uL 0,9-5,2

Monosit absolute 0,76 103/uL 0,16-1

Eosinofil 2,10 % 2-4

Basofil 0,00 % 0-1
Neutrofil 63,00 % 50-70
Limfosit 26,80 % 25-40
Monosit H 8,10 % 2-6
Chemical Clinic Serum

Glukosa
84 U/L 0-35
sewaktu

Ureum 14,0 U/L 0-35

Creatinin 0,88 mg/dL < 125
Kalium 3,6 mgdL 10,00-50,00
Natrium 138 Mg/dL 0,70-1,10
Chlorida 100 mmol/L 3,5-5,0
Total Protein 7,0 mmol/L 135-145
Albumin 3,7 g/dl 3,2-5,2
Globulin H 3,3 g/dl 2,9 -3,0
Rontgen Thorax (27th August
2013) COR
ctr<50%, location &
shape normal
PULMO
Shade s of vascular -
normal,
Spotting gloom (-)
Diaphragm: Good
Sinus costophrenicus:
taper
Kesan :
Cor : normal
Pulmo : normal
ECG (28 August 2013)
th
EGD (5 september 2013)
th

ESOPHAGUS :
Upper third : Normal
Middle third: Normal
Lower third : Normal
STOMACH
Cardia : Normal
Fundus : Hiatus Hernia mild
Corpus : Hiperemis, erosiv, ulcer
Antrum : Hiperemis, erosiv
Pylorus : Normal
DUODENUM
1st part : Normal
2nd part : Normal
Info tamb. : no spontaneus bleeding
CONCLUSION : Ulcer Gaster
Hiatus Hernia
ADVICE : Therapy PPI
 ABNORMAL LIST
History Talking
1. Chest pain is felt on the left side and extends to
the left shoulder and left back
2. nausea(+)
3. vomitus (+)
4. heartburn(+)
5. dizziness (+)
6. Cold sweat(+)
7. Decreased appetite
8. Patients admitted irregular diet every day
9. Hypertension history
10.Gastritis history
 Examination Physical
11. General status : look weak
12. Press pain on the epigastrium

Support Examination
13.Monosit (H)
14.Globulin (H)
15.EKG : non specific Twave abnormality
16.EGD : Ulkus Gaster dan Hiatus Hernia
 LIST PROBLEM
Angina Pectoris : 1,5,6,9,14,15
dispepsia Syndrome : 2,3,4,6,7,8,10,11,12,13,
16

Problem 1 : angina
pectoris
Ass. Etiology
Kardial Ass. Risc Factor
Pericardial Smooking
Aorta Hiperlipidemi
Pulmonal Hipertension
Ass.complication
Obesitas
Heart failure
Aritmia
DM
Infark miokard phsycologic
Sudden death Minim excercise
ipDx: pharmacologic
Blood test O2 2lt
ECG Infus RL 20 tpm
Rontgen Thorax P.O ISDN 3x 5 mg
CPK P.O Alprazolam 2 x
CK-MB 0,5 mg
Troponin P.O Amlodipine 1 x 5
mg
ipTx: consul Sp.PD
Non pharmacologic
Bed rest ipMx: Vital signs,
general status, chest
avoidi stress
pain
Ip. EX :

Education about her dissease

Bed rest
Avoid stress
eat nutritious foods
PROBLEM 2 : Dispepsia
Syndrome
Ass. Etiology Ass. Risc Factor
Helicobacter pylori diet
Ass.complication Consumption
Upper coffee & tea
gastrontestinal smooking
bleeding Alcohol
Peptic ulcer Consumption
NSAID long term
Stress
ipDx: ipMx: Vital signs,
general status,
EGD
nausea, vomitus,
Rontgen feses
gastrointestinal

Ip. EX :
ipTx:
Infus RL 20 tpm
Education to make
Inj ranitidine 2 x 1
a habit to eat
Inj ceftriaxone 2 x 1 regularly
Inj ondansetron 3 x 4 Education to avoid
mg foods that are too
P.O Omeprazole 2 x 1 hot and too cold
P.O Donperidon 3 x 1 education to avoid
Antasid Syr. 3 x 10 cc foods that are spicy
consul SP. Pd and sour
Avoid stress
 PROGRESS NOTE
Follow Up I (2nd september 2013)
S: nausea(+) , vomitus (+), dizzines (+), cold
sweat(+)
O
General status:look weak, composmentis
Vital sign:
BP: 110/70 mmHg
HR: 64 x / min
RR: 20 x /min
T : 36,10 C
Eye : normal
Thorax : normal
Abdomen
Inspeksi : normal P
Auskultation normal Infus RL 20 tpm
Percution : normal Inj ranitidine 2 x 1
Palpation : sociable Inj ceftriaxone 2 x 1
(+), press pain on the Inj ondansetron 3 x 4 mg
epigastrium P.O ISDN 3x 5 mg
P.O Alprazolam 2 x 0,5
mg
P.O Omeprazole 2 x 1
P.O Amlodipine 1 x 5 mg
Extremitas :normal P.O Domperidone 3 x 1
P.O PCT 3 X 1
A : angina pectoris Antasid Syr. 3 x 1
dispepsia syndrome
Follow Up II (3rd september 2013)
S: nausea(+) , vomitus (+), dizzines (+), heartburn,
the colour of feses is black
O
General status:look weak, composmentis
Vital sign:
BP: 90/70 mmHg
HR: 68x / min
RR: 20 x /min
T : 36,30 C
Eye : normal
Thorax : normal
Abdomen
Inspeksi : normal P
Advice : EGD
Auskultation normal
THERAPY
Percution : normal
Infus RL 20 tpm
Palpation : sociable
Inj ranitidine 2 x 1
(+), press pain on the
epigastrium Inj ceftriaxone 2 x 1
Inj ondansetron 3 x 4 mg
P.O ISDN 3x 5 mg
P.O Alprazolam 2 x 0,5 mg
P.O Omeprazole 2 x 1
P.O Amlodipine 1 x 5 mg
Extremitas :normal
P.O Domperidone 3 x 1
P.O PCT 3 X 1
A : angina pectoris
Antasid Syr. 3 x 1
dispepsia syndrome
Follow Up III (4th september 2013)
S:Left chest pain, nausea(+), vomitus (+), dizzines
(+), the colour of feses is black
O
General status:look weak, composmentis
Vital sign:
BP: 120/80mmHg
HR: 76x / min
RR: 20 x /min
T : 36,80 C
Eye : normal
Thorax : normal
Abdomen
Inspeksi : normal P
Advice : EGD
Auskultation normal
THERAPY
Percution : normal
Infus RL 20 tpm
Palpation : sociable
Inj ranitidine 2 x 1
(+), press pain on the
epigastrium Inj ceftriaxone 2 x 1
Inj ondansetron 3 x 4 mg
P.O ISDN 3x 5 mg
P.O Alprazolam 2 x 0,5 mg
P.O Omeprazole 2 x 1
P.O Amlodipine 1 x 5 mg
Extremitas :normal
P.O Domperidone 3 x 1
P.O PCT 3 X 1
A : angina pectoris
Antasid Syr. 3 x 1
dispepsia syndrome
Follow Up IV (5th september 2013)
S:heartburn, nausea(+), vomitus (+), dizzines (+),
the colour of feses is black
O
General status:look weak, composmentis
Vital sign:
BP: 110/70mmHg
HR: 68x / min
RR: 20 x /min
T : 36,30 C
Eye : normal
Thorax : normal
Abdomen P
Inspeksi : normal Advice : EGD
Auskultation normal THERAPY
Percution : normal Infus RL 20 tpm
Palpation : sociable Inj ranitidine 2 x 1
(+), press pain on the Inj ceftriaxone 2 x 1
epigastrium Inj ondansetron 3 x 4 mg
P.O ISDN 3x 5 mg
P.O Alprazolam 2 x 0,5
mg
P.O Omeprazole 2 x 1
Extremitas :normal P.O Amlodipine 1 x 5 mg
P.O Domperidone 3 x 1
A : angina pectoris P.O PCT 3 X 1
dispepsia syndrome Antasid Syr. 3 x 1
EGD
CONCLUSION :
Ulcus Gaster
Hiatus Hernia
ADVICE :
Therapy PPI
Follow Up V (6th september 2013)
S:heartburn, nausea(+), vomitus (+), dizzines (+),
the colour of feses is black
O
General status:look weak, composmentis
Vital sign:
BP: 110/70mmHg
HR:72x / min
RR: 20 x /min
T : 36,10 C
Eye : normal
Thorax : normal
Abdomen P
Inspeksi : normal THERAPY
Auskultation normal Infus RL 20 tpm
Percution : normal Inj ranitidine 2 x 1
Palpation : sociable Inj ceftriaxone 2 x 1
(+), press pain on the Inj ondansetron 3 x 4 mg
epigastrium Inj PPI (Omeprazole) 2 x 1
P.O ISDN 3x 5 mg
P.O Alprazolam 2 x 0,5
mg
P.O Omeprazole 2 x 1
Extremitas :normal P.O Amlodipine 1 x 5 mg
P.O Domperidone 3 x 1
A : angina pectoris P.O PCT 3 X 1
dispepsia syndrome Antasid Syr. 3 x 1
Follow Up VI (7th september 2013)
S:nausea(decrease), vomitus (-), yet defecate
General status:enough, composmentis
Vital sign:
BP: 140/90 mmHg
HR:64x / min
RR: 20 x /min
T : 36,40 C
Eye : normal
Thorax : normal
Abdomen P
Inspeksi : normal THERAPY
Auskultation normal Infus RL 20 tpm
Percution : normal Inj ranitidine 2 x 1
Palpation : sociable Inj ceftriaxone 2 x 1
(+), press pain on the Inj ondansetron 3 x 4 mg
epigastrium Inj PPI (Omeprazole) 2 x 1
P.O ISDN 3x 5 mg
P.O Alprazolam 2 x 0,5
mg
P.O Omeprazole 2 x 1
Extremitas :normal P.O Amlodipine 1 x 5 mg
P.O Domperidone 3 x 1
A : angina pectoris P.O PCT 3 X 1
dispepsia syndrome Antasid Syr. 3 x 1
THANK YOU