Emergency Duty Report

Wednesday, August 12th

2020
Consultant incharge : dr. Kino, SpJP (K)

Residen incharge : dr. Putri Handayani/ dr. Deddy/ dr. Sisca/ dr.
Riski/ dr. Medika
 Old Patient New Patient Problemed Died

Yellow
CVCU Ward CVCU Ward CVCU Ward CVCU Ward
Zone

3 8 2 - 2 - - - -
 Patient in consult

Patient Diagnosis Treatment

1 Naimah, 80 y.o, • HT Stg II • Amlodipin 1x5mg (morning)
00.09.70.83 • Aspiration Pneumonia • Candesartan 1x8mg (night)
• Sequele ischaemic
stroke
 New Patient
Mr. Muzaini/ 65 y.o/ 00.30.33.10
UAP timi 4/7, GS 87
ASHD post PTCA 1 stent in prox-mid
LAD (2017), 1 stent in prox-mid LCX
(2018), 1 stent in mid-distal LAD (2018)
HT stg II
Type II DM
 PATIENT WILL BE REPORTED
Mr. Muzaini/ 65 y.o/ 00.30.33.10
Chief complaint
Chest pain since 10 hours before admission

Present Illness
Chest pain since 10 hours before admission, in the middle of chest, duration < 30 minutes, radiation (-), diaphoresis
(-), nausea (+) and vomiting (-). History of chest pain (+) 1 stent in prox-mid LAD (2017), 1 stent in prox-mid LCX
(2018), 1 stent in mid-distal LAD (2018). Patient routinely controlled with cardiologist and got therapy bisoprolol
1x5mg, amlodipine 1x5mg, ASA 1x100mg, Imidapril 1x5mg, Short acting insulin 1x12 IU, Long acting insulin 3x12
IU.
Shortness of breath (-). DOE (-), OP (-), PND (-), leg swelling (-)

Palpitation (-), dizziness (+) since 3 hours before admission, syncope (-).
Patient was referred from SPH and diagnosed with UAP and already got therapy Enoxaparin 2x0.6cc, ASA 1x100mg,
Bisoprolol 1x7.5 mg, Amlodipin 1x10mg, Imidapril 1x10mg, NTG 20mcg/min, Short acting insulin 1x12 IU, Long
acting insulin 3x12 IU, Lansoprazole 1x30mg.
At emergency : chest pain (+) with scale 2/10

Risk factors
 Ex Smoker (+), stop smoking since 2 years ago
 Hypertension (+) since 10 years ago controlled with amlodipine 1x10mg, imidapril 1x10mg
 DM (+) >5 years ago, controlled by insulin
 FH (-)
 Dislipidemia (?)

Past Illness
asthma (-), gastritis (-), stroke (-)
Physical Examination
General appearance : Moderate
Sens : CMC
Blood Pressure : 158/85 mmHg
Pulse Rate : 66 x/min
Resp Rate : 20 x / m
Neck : JVP 5+0 cmH20
SaO2 : 98 % Room Air
Pulmo:
insp : Symetric right = left
palp : Fremitus right = left
perc : Sonor right = left
ausc : Vesiculer (+), rales -/-, wheezing -/-

Cor :
insp : Ictus cordis not visible
palp : Ictus cordis palpable at LMCS 5th ICS
perc : Upper : 2nd ICS
Right: LSD
Left : at LMCS 5th ICS
ausc : S1N-S2N reguler, murmur -, gallop -
Abdomen
insp : Supel
palp : Hepar and lien was not palpable
perc : Tympani
ausc : Peristaltic sound (+) N

Extremities :
Edema -/-, warm
 ECG at ER (13/8/2020 )

SR, QRS rate 60 x/m , Axis LAD, P wave N, PR int 0,16 s, QRS dur 0,06s,
ST – T change (-), LVH (-), RVH (-)
Laboratory Findings
Hb : 13.5 g/dl Ur/Cr : 28/1 mg/dl

Leucocyte : 11.730 /mm3 CCT : 63

Ht : 40 % RBG :
314mg/dL
Platelet : 274.000 /mm3
Trop I : 22 ng/L
Na/K/Cl/Ca : 140/3.7/107/8.1
BGA
pH : 7.41
pCO2 : 33
pO2 : 168
HCO3 : 20.9
BE : -3.7
SAO2 : 100%

Normal BGA
Chest X-Ray

CTR 58% , Sg Ao N, Sg Po N , CW (+ ), apex downward, cranialization(-), infiltrate (-)

CTR 58% , Sg Ao N, Sg Po N , CW (+ ), apex downward, cranialization(-), infiltrate (-)
TIMI RISK
 Age 65 yo : 0
 >3 FR (+) : 1
 CAD (+) : 1
 Biomarker (-) : 1
 ST segment deviation (-) : 0
4/7
 Angina (-) : 0
 ASA 7 days (+) : 1
GRACE SCORE
 Age 65 yo : 53
 HR 66 : 0
 TDS 158 : 26
 Killip I: 0
 Cr 1.0 : 8
 Cardiac Arrest (-) : 0
 Biomarker (-) : 0
 ST-T changes (-) : 0

87
DIAGNOSIS
◦ UAP TIMI 4/7 GS 87
◦ ASHD post PTCA 1 stent in prox-mid LAD (2017), 1 stent in prox-mid LCX (2018), 1
stent in mid-distal LAD (2018)
◦ HT stg II
◦ Type II DM
Therapy in ER
NTG 20 mcg

Enoxaparin 2x0.6cc

ASA 1x100mg

CPG 1xx75mg

Bisprolol 1x25mg

Amlodipin 1x10mg

Imidapril 1x10mg

Glyceryl trinitrate 2x2.5mg

Criticall ill insulin

Plan
Consult to DPJP Covid  Greenzone
Consult to Internal medicine
Profil lipid test
Keton urine test
TERIMA KASIH