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    Hesty Simanjuntak
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    A 45-year-old female patient presented to the emergency unit with a chief complaint of crushing chest pain radiating to her back for the past 6 hours. She reported a history of coronary artery blockage. On examination, she had pale conjunctiva, tachycardia, tachypnea, and rales in her lungs. Laboratory tests showed anemia. Her electrocardiogram and assessments indicated NSTEMI and CHF. She was admitted to the hospital and prescribed IV fluids, lasix, ranitidine, bisoprolol, aspirin, and nitroglycerin for treatment.

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    morport

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    48483_team 5 Morpot 21 November

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    A 45-year-old female patient presented to the emergency unit with a chief complaint of crushing chest pain radiating to her back for the past 6 hours. She reported a history of coronary artery blockage. On examination, she had pale conjunctiva, tachycardia, tachypnea, and rales in her lungs. Laboratory tests showed anemia. Her electrocardiogram and assessments indicated NSTEMI and CHF. She was admitted to the hospital and prescribed IV fluids, lasix, ranitidine, bisoprolol, aspirin, and nitroglycerin for treatment.

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    © All Rights Reserved
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    8 views10 pages

    Department of Internal Medicine: Morning

    Uploaded by

    Hesty Simanjuntak
    A 45-year-old female patient presented to the emergency unit with a chief complaint of crushing chest pain radiating to her back for the past 6 hours. She reported a history of coronary artery blockage. On examination, she had pale conjunctiva, tachycardia, tachypnea, and rales in her lungs. Laboratory tests showed anemia. Her electrocardiogram and assessments indicated NSTEMI and CHF. She was admitted to the hospital and prescribed IV fluids, lasix, ranitidine, bisoprolol, aspirin, and nitroglycerin for treatment.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 10

    Department of Internal

    Medicine
    Christian University of Indonesia

    MORNING
    REPORT
    November 21th
    2016
    TEAM 5

    Subjective Data
    Name
    : Mrs. Nikmah, 45 years old
    TC
    : Friday, November 21th 2016
    CC
    : Crushing discomfort

    Chronological Order of
    Anamnesis
    A female patient came to the emergency unit with a chief
    complaint of crushing discomfort in her chest radiating
    throughout her back, continuously within the last 6
    hours. The feeling was described as a sensation of being
    crushed, painfully dull, and occured while the patient was
    resting. she hasn't took any medications, and mentioned
    a history of heart condition, she was diagnosed with
    coronary artery blockage several months ago while
    checking up on another hospital with a similiar
    complaint. the patient had other complaints of breathing
    difficulty, especially while sleeping which prompted her
    to be awakened at night. she also admitted to sleep with
    two layers of pillow to ease the complaint.

    Objective Data

    Appearance : Moderate Illness


    Glasgow Coma Scale : E4M6V5
    Blood Pressure : 90/60 mmHg
    Respiratory Rate : 44 x/minute
    Temperature : 36.0C
    Pulse : 100 x/minute.
    Eye: Pale conjunctiva +/+ ,
    Sclera icteric -/ Ear, Nose, Throat : Normal
    Neck : Lymph nodes not
    enlarged

    Physical
    Examination
    Thorax.

    Inspection : Symmetrical chest wall movement, Ictus


    cordis (+)
    Palpation : Symmetrical Vocal fremitus, ictus cordis :
    palpable on the left 5th ICS radiating unto the left
    anterior axillary line.
    Percussion : Sonor/Sonor, right = left
    Auscultation : Basic breath sound bronchovesicular,
    ronchi +/+, wheezing -/-. S1 and S2 reguler, gallop (-),
    murmur (+)
    Abdomen.
    Inspection : Flat
    Auscultation : Bowel sound (+) 5/minute
    Palpation : Pressure pain (-)
    Percussion : Timpani, Percussion tenderness (-)
    Extremity
    Warm acral
    Capillary refilling time <2 second

    Clinical Laboratory

    07/11/2016
    H2TL

    Hb
    14,2 g/dl

    Electrolit
    :

    Hematocrite :
    43,1%
    Trombosite : 337
    rb/uL
    Leukocytes: 9,1
    rb /uL

    Natrium 130
    Kalium
    3.1
    Clorida 98
    Ureum
    : 43 mg/dl
    Creatinine : 0,8mg/dl
    blood glucose: 124
    mg/dl

    12-Lead
    Electrocardiography

    Assessment
    1. NSTEMI
    2. CHF

    Therapy
    PRO-HOSPITALIZED
    IVFD :
    I RL kolf 500ml / 24 jam
    Mm /
    Furosemide 1x1
    (iv)
    Ranitidine 2x1 gr
    (iv)
    Micardis (Bisoprolol) 1x1 (PO)
    Trombhoaspilet 1x1 (PO)
    Nitrokaf retard 1x1 (PO)

    Department of
    Internal Medicine
    Christian University of
    Indonesia

    Thank
    You

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