MORNING REPORT

Thursday, September 26th, 2019

Presenter:
Amira Fithri Rofifa
201910401011065

Consultant:
dr. Vitriyaturrida, SpJP
  Name : Tn. Faizul
 Sex : Male
 Age : 35 years old
Identity  Address : Nyala Budaya
 Hospitalized : Friday, November 30 th 2019, 23.00  IGD
 00.50  ICU
  Mr. F,35 years old
 Main complaint: chest pain
 Patient felt chest pain that radiating to left elbow since 7 pm.
SUBJECTIVE He felt chest pain when he was smoking. The duration of chest
pain is more than 30 minutes,he feels his chest pressed down,
He found that her chest pain relieved when she was resting but
suddenly he feel chest pain again. He was vomiting 2 times and
feel nausea. This is the first time he feels it.
  History of the disease:
 DM (-)
 Chest pain (-)
Summary of  HT (+)

Database  History of the social-relation:

 Patient is smoking 2 packs of cigarretes a day
 History of the therapy:
 he doesn’t memorized the drug she has taken
  General condition : pain VAS 8/10
 Awareness : Compos Mentis
 Vital Sign: BP: 183/123, HR:109 x/minute, Temp: 36,3, RR: 20
x/minute,SpO2: 100 %
 Head/Neck : Conjuctiva pale -/-, icteric sclera -/-
Thorax
OBJECTIVE Cor: Ictus cordis invisible, not palpable. Single S1-S2 , murmur (-),
gallop (-)
Pulmo: symmetrical, rh -/-,wh -/-
Abdomen :
Soefl, tenderness(-), Bowel sound (+) Normal
Extremities
Edema -/-, warm acral +/+
 CXR
September, 26th 2019
 AP position, symmetrical
 Bone: Costa R/L normal
 ICS R/L normal
 Trachea: In the middle
 Hillus R/L: N
 Cor: Site: N
 Size: CTR 73 %
 Cardiac waist (+)
 Hemidiaphragm:
 R: dome-shaped
 L: dome - shaped
 Costophrenic angles: right – left
sharp
 Pulmo: Normal

 Conclusion : Cardiomegaly
 Laboratory Finding
Date: September, 25th Parameter Result Normal Value
2019
Hb 15.8 g/dL 13.4 – 17.7 g/dL

Leukocytes 11.450 /µL 4300-10300/µL

Eritrosit 5.57 juta 4.5 – 6.2 juta/cmm

Hematocrit 45,6 % 40 – 47 %

Thrombocytes 225.000 /µL 142000-424000/µL

Random Blood 193 g/dL <200 mg /dl

Sugar
 ASSESSMENT TREATMENT
1. Supraventricular tachycardia Planning Diagnosis :
Serial ECG

Planning Therapy :
Bedrest
O2 Mask 15 lpm
Infus PZ 0.9 % 500 cc/24 hour
Inj. Herbesser 0,25 mg/kg for 2 minutes

Asking for advice from Cardiologist

 ASSESSMENT TREATMENT
1. Acute on chronic Heart failure Planning Diagnosis :
stadium C Functional class III Serial ECG, Echocardiography, cardiac marker
Precipitat factor ACS
Planning Therapy :
Bedrest
O2 Mask 15 lpm
Infus PZ 0.9 % 500 cc/24 hour
ACEI
Inj. Furosemid 3x 40 mg I.V

Asking for advice from Cardiologist

 ASSESSMENT TREATMENT
1. NSTEMI dd UAP Planning Diagnosis :
Serial ECG, Echocardiography, cardiac marker

Planning Therapy :
Bedrest
O2 Mask 15 lpm
Infus PZ 0.9 % 500 cc/24 hour
CPG 300 mg
Aspilet 320 mg
Atorvastatin 1 x 40 mg po
Anticoagulant: LMWH (Lovenox)/UFH
(Heparin)/Fondaparinux

Asking for advice from Cardiologist