Morning Report

Wednesday, February 19th 2014 Coass in charge: nur,ratih Ward : cvcu Prof.Dr.dr.Djanggan, SpJK (K) Consultant on duty : MR consultant:

SUMMARY OF DATABASE
Mr Kuat / 52 y.o
Chief Complaint : Chest pain
Male/52yo/W.CVCU
Chief complaint: Chest pain Patient has been suffering from chest pain abrupt onset at home, after he come back from work (30 minute before arrived at ER), he couldnt describe the location and its about 20 minutes and happened continously. The chest pain was heavy-like sensation, excessive of cold sweating, and not relieve with rest but there was no complaint about shortness of breath. He said he didnt took drugs for 3 days before admission because he said his blood pressure is normal. After he felt chest pain, he took drugs: ASA 80 mg and CPG 75 mg at home, and his family imidiately brought him to RSSA, at the ER, after perform ECG and laboratory he was given ASA 3 tablet and CPG 3 tablet again from the doctor. History has previous typical chest pain twice, at 2005 admitted in CVCU for 8 days and 2011 for 8 days He had been diagnosed HT since 10 years ago, routinely control and took medication (valsartan 1x80, ASA 1x80, Simvastatin 1x20mg), highest BP about 160/He is a active heavy smoker since youth (12 bar/day) and stopped since 2005 after felt chest pain. He is a pharmacist at RSSA, have 2 children and never drink alcohol.

PHYSICAL EXAMINATION-CVCU
General appearance Vital sign Looks moderately ill BP 149/92 mmHg HR 87tpm RR 18 tpm

Head
Neck Thorax : Heart &Lung

Pale conjungtiva -,IctericJVP R + 0 cmH2O at 30o Ictus invisible palpable at ICS V 1 cm lat MCL (S) RHM SL D LHM as ictus S1,2 normal , gallop (-) murmur (-) Simetric, Rh - Wh -----Flat,bowel sound (+) normal, soefl, H/L unpalpable, liver span 8 cm, troube space tympany Warm acral, Edema(-), Cyanosis (-)

Abdomen Extremities

LABORATORY FINDING
Lab Leuco Hb Thrombo PCV RBS Ureum Creatinin SGOT SGPT value 8.920 13.4 39.2 138 27.0 1.26 45 16 /L g/dl % mg/dl mg/dl mg/dl U/L U/L Normal value 3.500-10.000 11-16.5 150-390.103 35-50 <200 10-50 0,7-1.5 11-41 10-41 CPK CKMB Trop I Na K Cl Lab Value 108365 1951 0.01,3 138 3.96 109 u/L u/L Ng/ml mmol/L mmol/L mmol/L Normal value 30-190 <25 Neg 136-145 3,5-5 98-105

262.000 /L

ECG at ER at 18.00

0 0 0 0 0 0 0 0 0

Sinus rhyth, Heart rate 90 bpm Frontal Axis : LAD Horizontal Axis : normal PR interval : 0.12 QRS complex : 0.08 QT interval : 0.40 ST elevation I, AVL ST depresion III, AVF Conclusion: sinus rhythm with heart rate 72 bpm, STEMI high laterall wall,

CXR

0 AP position, symmetric, strong KV, less inspiration

0 Soft tissue thin, Bone normal

0 Trachea in the middlle 0 Hemidiaphragm D/S dome shape 0 Phrenico costalis angle D/S sharp 0 Pulmo D/S :normal 0 Cor: site N, size CTR 60%

Conclusion : less inspiration looks cardiomegaly

CUE AND CLUE

PROBLEM LIST

INITIAL DIAGNOSE

PLANING DIAGNOSE

PLANNING THERAPY

PLANNING MONITOR

1. Mr K/52 yo
Ax: chest pain since 5 pm (30 minutes before admission) heavy like sensation, >20 minutes, continuesly not relieved with rest. History HTN since >20 years poorly controlled, Smoking since youth, quit 9 years ago Family history History hospitalized 2x because of chest pain PE : BP BP 150/90mmHg HR 89tpm RR 18tpm ECG : Sinus rhytm with ST elevation I, AVL, ST depression II, III, AVF Lab : CKMB 19 51 Trop I 0.0 1,3

1.STEMI high lateral onset < 1 hour TIMI score 1/14 KILLIP I GRACE 98

Coronary angiography , Echo, Lipid profile

O2 4 lpm NC Bed rest Semifowler position Insert urine condom catheter Fluid balance 0/24h IVFD NacL 0.9% 1500 cc/24 hours Inf. Streptokinase no stock Inj. LMWH (enoxaparin )2 x 0.6 cc sc Po. ASA lx 80 mg CPG 1 x 75 mg Alprazolam 0-0-0.5mg Simvastatin 0- 0- 20 mg ISDN 3 x5 mg Stool softener 3 x CI

S VS ECG

CUE AND CLUE

PROBLEM LIST

INITIAL DIAGNOSE

PLANING DIAGNOSE

PLANNING THERAPY

PLANNING MONITOR

2. Mr K/52 yo Ax : history HTN known since 20 years ago Routionelly controlled to cardiology outpatient department PE : BP 150/90mmHg

2. Hypertension st I (on treatment)

2.1 essential 2.2 secondary

As above Valsartan 1x80mg

S VS

Thank you