Brief Report

th
Monday, October 17 2016
Resident incharge :
dr. Reza/dr. Atik/dr. Faisal/dr.Nizam/dr.Rakhmi (IPD)/dr.
Fadli/dr.Eldi

Consultant : dr. Indra Prasetya, Sp. JP

MR moderator : dr. Indra Prasetya, Sp. JP
S O
Mr. M/44 years old compos mentis
GCS 456
Chief Complain: Trancient loss of consiousness BP : 115/64 mmHg
Patient complain headache and syncope at Klinik HR : 62 bpm regular
Turen (people around him said patient syncope) RR : 18 x/mins
during 3 minute after that patient awake. Then Sp02 : 97% room air
patient vommit 1x after that patient feel better. Head and neck :
Patient complaint all over that since evening An (-) Ict (-) JVP R+1cmH2O at 30 position
during rest at 04.00pm Th: cor : ictus invisible, palpable 5th ICS 1 cm
Fever (-) Nausea & vomitting (+) since yesterday lateral left MCL
at 04.30 pm. History syncope (-) Chest pain (-) S1S2 normal murmur (-) gallop (–) wide split S2
DOE (-) Palpitation (-) PND (-) leg swelling (-) Pulmo : v/v rh -/- wh -/-
History of past illness : HT (-) DM (-) v/v -/- -/-
Smoker since patient aged 15 years old 1 v/v -/- -/-
pack/day and then stop 7 years ago Abd : soefl, normal bowel sound
Family history : HT (-) DM (-) heart disease (-) Ext : warm acral -/- edema -/-
He was a driver, had 2 children -/- -/-
ECG at Turen
October 16th 2016
ECG at RSSA
October 17th 2016
ECG at RSSA
October 17th 2016
 Chest X Ray
August 18th 2016

•AP position, asymetric, KV

enough, less inspiration
•Trachea in the middle, Soft
tissue thick and normal bone
•Aorta calcification (-)
•Right and left phrenicocostalis
sharp
•Lung: Infiltrat (-), hillus
thickening (-)
•Cor: CTR: 54 %, cardiac waist
(+)
•Conclusion: Cardiomegaly
 LABORATORY FINDINGS
October 17th 2016
Laboratory Result Normal Value Laboratory Result Normal Value

Hb 14,50 13,4 – 17,7 g/dL Ureum 34,20 16.6-48.5

Leucocyte 11,52 4.300-10.300/µL Creatinin 1,03 < 1,2

Hematocrit 42,50 40 – 47 %

Thrombocyte 293 142.000-424.000/µL GDS 159 <200

MCV 73,80 80 – 93 fL

MCH 25,20 27 – 31 pg Serum ELectrolyte

MCHC 34,10 32 – 36 g/dL Na 139 136-145

Eos/Bas/Neut/Ly 0,1/0,3/88,4/ 0-4/0-1/2-6/35-67/20- K 4,45 3.5-5.0

mp/Mono 8,1/3,1 35/2-5 %
SGOT 33 0-40 U/L Cl 109 98-106
SGPT 30 0-41 U/L

Albumin 3,63 3.5-5.5

 LABORATORY FINDINGS
October 17th 2016
Laboratory Result Normal Value

Trop-i 1,70 < 1,0 µg/L

CK-MB 30 7 - 25U/L
 Echocardiography

• EF : 31%
• LV Diastolic function : E/A : 1,2 e/e’ :16
• RV systolic function : TAPSE : 1,4
• Hypokinetic at inferoseptal, anteroseptal and anterior segments at basal
and mid
• RV and RA normal
• LV concentric remodelling
• Mild MR
A P

1. Syncope dt. sinus pause Planning Dx :

2. Sinus pause – alternatiry wekenbach Lipid Profile, GD I/II, UA
3. Riw. Smoker Echocardiography
4. Susp. Myocarditis Holter Monitoring

Planning Therapy:
Fluid Total 2000cc/day
Fluid balanced
IVFD NaCl 0,9% 1000cc/day
DJ IV
Inj. Sulfas Atropine 0,5mg iv if bradycardia
symptompatis with maximal dose 3mg
Oral: Captopril 3 x 6,25mg

Planning Monitoring :
S, VS