MEDICAL CONSULTATION

from Cardiology Department

Patient with
1. STEMI anterior wide extensive TIMI 6 Grace 127 Killip II
2. AKI stage 2
3. HF stage C FC III
4. DM tipe 2 on insulin
5. Hipertensi on Treatment

The aim of consultation

Management of Azotemia and DM Type 2
 SUMMARY OF DATABASE

Mr. M/61 yo/W. CVCU bed 1

Autoanamnesis

Chief Complaint : no urinary output since 5 pm

HISTORY OF PRESENT ILLNESS :

Patient complained about no urinary output since 5 pm. Dysuria (-). He had
urinary catheter attached. There was brownish red liquid in his urinary catheter
after spooling procedure. He had history of normal urination before. No history of
sandy urination (kencing berpasir).
He was hospitalized because of chest pain since 3 days ago, felt like pressing
sensation in his left chest. It relieved with rest. and diagnosed with STEMI anterior
wide extensive TIMI 6 Grace 127 Killip II
He had diagnosed with type 2 DM since 4 days ago and got insulin levemir 0-
10 unit. He had history of HT since 4 years ago and routinely consumed amlodipin
1x10 mg
 SUMMARY OF DATABASE

PAST MEDICAL HISTORY & MEDICATION:

• He had history of DM and HT
ALLERGY HISTORY :
• No history of allergy was recorded from the patient.
FAMILY HISTORY :
• Hipertension (+), DM (-), CAD (-)
SOCIAL HISTORY :
• He was married and had 2 children.
REVIEW OF SYSTEM :
• Her urination was decreased
• Nausea (-)
 PHYSICAL EXAMINATION
General appearance looked GCS 456 Sat O2 96% NRBM 10 lpm
moderately ill
Looked overweight, BMI 28.77 (BW 80 kg, height 167 cm)
BP 102/54 mmHg PR 98 bpm regular strong RR 22 tpm Tax 36,8 oC

Head Conjunctiva Anemic (-)

Neck JVP R+2 cmH20, lymph node enlargement (-)
Chest Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : Wheezing :
-|-
-|-
Sonor | Sonor Vesicular | Vesicular -|- -|-

Sonor | Sonor Vesicular | Vesicular +|+ - |-

Cardio Ictus invisible, palpable at ICS V 2 cm lateral MCL S
S1 S2 single, regular, murmur (-) gallop (-)
Abdomen Soefl, round, bowel sound (+) normal, shifting dullness (-), mass (-)

Extremities Edema -/-, warm acral

UOP 0 cc/6 hours, (red to brown colour in spooling catheter)
 LABORATORY RESULT (20/02/2021)
LAB VALUE NORMAL LAB VALUE NORMAL

Hemoglobine 12,2 11,4 - 15,1 g/dl Ureum 58,3 20-40 mg/dL

Leucocyte 16.970 4.700 – 11.300 /µL Creatinine 2,43 <1,2 mg/dL

PCV 35.4 38 - 42% BUN/Cr 11,19 postrenal
150.000 –
Thrombocyte 262.000 eGFR 27,64 ml/min/1,73 m2
400.000 /µL
GDS 142 <200 mg/dL CKMB 37 7-25
ECLIA NR NR Troponin I 15 <1
Natrium 138 136-145 mmol/L
Kalium 4,08 3,5-5,0 mmol/L
Cloride 100 98-106 mmol/L
CHEST XRAY (20/02/2021)
 CHEST XRAY INTERPRETATION

▪ PA position, symmetric, enough KV, enough inspiration

▪ Trachea was in the middle
▪ Soft tissue and bone look normal
▪ Right and left diaphragma were domeshape
▪ Right and left costophrenico angle were blunt
▪ Pulmo : bronchovascular pattern was Normal, infiltrat/cavity/nodule (-)
▪ Cor : site N, shape N, cardiac waist straight, CTR 78%, left cardial margin
attached to left thorax wall
▪ lamelar opacity at hemitorax dextra et sinistra, covered costophrenicus
angle dextra et sinistra and part of hemidiaphragm dextra et sinistra

Conclusion : cardiomegaly
ELECTROCARDIOGRAM (20/02/2021)
 ECG INTERPRETATION

▪ Sinus tachycardia, HR 102 bpm reguler

▪ Frontal axis normal
▪ Horizontal axis clockwise rotation
▪ P wave normal
▪ PR interval 0,16”
▪ QRS complex 0,10”
▪ Q wave pathological V1-V5
▪ QT interval 0,35”
▪ ST segment elevation V2-V5, I, AvL. ST depression II, III, AvF
Conclusion : sinus tachycardi, HR 102 bpm with STEMI
anterior extensive
 PROBLEM ORIENTED MEDICAL RECORD
CUE AND CLUE PL Idx PDx PTx PMo&Ed
Mr.M/61 yo/Ward CVCU 1. STEMI anterior Treatment by Cardiology Pmo :
Bed 1 wide extensive departement S, VS, ECG,
TIMI 6 Grace 127 - IVFD NS 500 cc/24 hours Cardiac enzim
Subjective Killip II - Oral intake 1000 cc/24 hours
- Left chest pain since 3 - Negative fluid balance P.Ed :
days ago - 02 NRBM 8-10 lpm Progression
- HT since 4 years ago - Drip Heparin 940 IU/hours of disease
- Drip ISDN 5 mg/hours Prognosis
Laboratory (21/02/2021) - IV Furosemide 3x40 mg
Troponin I 15 - IV Lansoprazole 1x30 mg
CKMB 37 - PO Aspilet 0-0-80 mg
- PO Clopidogrel 75 mg-0-0
ECG (21/02/2021) - PO Atorvastatin 0-0-40 mg
ST elevation in leads V2-V4, I - PO Candesartan 0-0-16 mg
aVL, Q Pathological in leads - PO Bisoprolol 2,5 mg-0-0
aVL, V2-V6 - PO Laxadine syr 1xC
 PROBLEM ORIENTED MEDICAL RECORD
CUE AND CLUE PL Idx PDx PTx PMo&Ed
Mr.M/61 yo/Ward CVCU 2. AKI Stage 2 2.1 ATN dt low - Check Suggestion from Pmo :
Bed 1 cardiac output Urinalysis internal medicine : Subjective, VS
dt Heart Failure - USG ‐ Negative Fluid Ur / Cr per 24
Subjective abdomen Balanced hours, UOP
- Anuria since 6 hours ago 2.2. Obstructive to rule out ‐ Monitoring UOP,
Uropathy the cause Currently we have not P.Ed :
Objective of renal found HD indication Progression
UOP 0 cc/6 hours, (red to obstruction ‐ HD CITO if renal of disease
brown colour in spooling emergency is found
catheter) (severe acidosis,
refractory
Laboratory (21/02/2021) hyperkalemia, anuria
Ur/Cr : 58,3/ 2,43 mg/dL; with signs of
BUN:cr ratio: 11,19 (renal overload, acute lung
- postrenal) edema, uremic
eGFR: 27,64 symptoms)
 PROBLEM ORIENTED MEDICAL RECORD
CUE AND CLUE PL Idx PDx PTx PMo&Ed
Mr.M/61 yo/Ward CVCU 3. HF stage C 3.1 HHD Echocardiograp Treatment by Pmo:
Bed 1 FC III 3.2 CAD hy Cardiology S, VS, UOP
3.3 DCM departement:
Subjective - IVFD NS 500 cc/24 P.Ed :
- DOE (+) hours Educate
- PND (+) - Oral intake 1000 regarding the
- Orthopneu cc/24hours patients
- History of HT since 4 - negative fluid condition
years ago balance
- History of DM since 4 - IV Furosemide 3x40
days ago mg
- PO Candesartan 0-0-
Objective 16 mg
UOP 0 cc/6 hours, (red to - PO Bisoprolol 2,5
brown colour in spooling mg-0-0
catheter)
C : Ictus cordis palpated ics V
2 cm lateral MCL Sinistra
Pulmo : Ronki at basal
sinistra and dextra

CXR 21/2/2021
Cardiomegaly
 PROBLEM ORIENTED MEDICAL RECORD
CUE AND CLUE PL Idx PDx PTx PMo&Ed
Mr.M/61 yo/Ward CVCU 4. DM type 2 on Suggestion from internal Pmo
Bed 1 insulin medicine : S, VS, FBG,
DM Diet (55 % 2PPBG,
Subjective Carbohydrate, 25 % HbA1C, Lipid
History of DM 4 days ago protein, 25% lipid) Profile
with insulin injection Evaluation the blood
(Levemir) sugar and HbA1C for the P.Ed :
treatment Progression
Lab 21/2/2021 of disease
RBS 142 mg/dl
 PROBLEM ORIENTED MEDICAL RECORD
CUE AND CLUE PL Idx PDx PTx PMo&Ed
Mr.M/61 yo/Ward CVCU 5. HT on 5.1 Primary fundusco Treatment by Cardiology Pmo:
Bed 1 treatment 5.2 Secondary py departement: S, VS, blood
- Low salt diet pressure
Subjective - IV Furosemide 3x40
- History of HT since 4 mg P.Ed :
years ago, History of HT - PO Candesartan 0-0- Educate
in family (+) 16 mg regarding the
- PO Bisoprolol 2,5 mg- patients
Objective 0-0 condition
BP 106/72 mmHg
TREATMENT GIVEN BY CARDIOLOGY DEPARTMENT
Non pharmacology
- Oral intake 1000 cc/24hours
- Fluid balance negatif
Pharmacology
- IVFD NS 500 cc/24 hours
- 02 NRBM 8-10 lPM
- Drip Heparin 940 IU/hours
- Drip ISDN 5 mg/hours
- IV Furosemide 3x40 mg
- IV Lanzoprazole 1x30 mg
- PO Aspilet 0-0-80 mg
- PO Clopidogrel 75 mg-0-0
- PO Atorvastatin 0-0-40 mg
- PO Candesartan 0-0-16 mg
- PO Concor 2,5 mg-0-0
- PO Laxadine syr 1xC
 WE SUGGEST THIS PATIENT

• Balanced Fluid Negatives

• Check Urinalysis
• USG of the abdomen to rule out the cause of renal obstruction
• Check GDP, GD2PP and HbA1C
• Monitoring UOP, Ur / Cr per 24 hours
• Currently we have not found HD indication
• HD CITO if renal emergency is found (severe acidosis, refractory
hyperkalaemia, anuria with signs of overload, acute lung edema, uremic
symptoms)

Patient will be collaborative care with Nephrology division if colleague and

patient give consent.
 PROBLEM ANALYSIS

Diabetes Mellitus type 2

STEMI

DCM

Heart Failure

Decrease renal
perfusion

HHD

Hypertension
AKI Stage 2
 CONDITION THIS MORNING

• GCS : 456
• BP : 102/61 mmHg
• HR : 102 bpm
• RR : 21 tpm
• Tax : 36,8 oC