Morning Report, 9 Feb 2020

Maya
Gofur
Idul
Tito
Yasni
Triani
Novi
Vandy
 PATIENT LIST
No. Patient Identity Diagnosis
1. Mrs. M/66 y.o • Post Cardiac Arrest
• Cardiogenic Shock
• NSTE ACS very high risk
• Hypertensive Heart Disease
 ID Patient
Name : Mrs. M
Age : 66 years
Date of Birth : 5-1-1954
Address : Takalar
MR :730146
Date of Admission : 9/2/2021
 History Taking
Chief complaint : unconsciousness
Since the patient was at the ER. Previously, she complained of chest pain since
14 hours before admission to Wahidin Sudirohusodo’s Hospital, pressed like
sensation, duration >20 minutes, radiated to the left arm and neck, diaphoresis
(+), there was nausea and vommiting. Chest pain trigerred by activity and not
relieved with nitrat. Shortness of breath (-).
• Risk Factors
– History of cardiovascular disease (+), coronary angiography 2015 at RSWS
advice to CABG but patient refused.
– History of Hypertension (+)
• Routinely medication at PJT polyclinic: concor 2,5 mg 1x1, miniaspi 80 mg
1x1, lisinopril 5 mg 1x1, nitrokaf 2,5 mg 2x1, amlodipin 10 mg 1x1,
atorvastatin 20 mg 1x1, alprazolam 0,5 mg 1x1.
 Physical Examination
• BP: not measuremnet
• Carotid pulse not palpable
• ECG monitor: asystole

• Assessment: cardiac arrest

• Management: CPR for 30 minutes + epinephrine 6 amp -->
ROSC (+)
Time Follow up Management
10/2/21 S: Post ROSC, unconsciousness Oxygen 15LPM/ Bag Valve Mask
00.30 Natrium Clorida 0.9% 500
O: BP : 40/palpation ml/intravenous
Pulse 90 bpm Dobutamin 10 mcg/kgBW/minute
SPO2 99% with Bagging Vascon 0.1 mcg/kgBW/minute
conjunctiva anemic (-), sclera icteric (-)
JVP R+2 cmH2O
Bronchovesicular breath sound, Rales (-), Plan:
Wheezing (-)  Laboratorium check
S1 S2 regular, No audible murmur  Blood Gas Analysis
Extremities : Bilateral oedema (-), Cold , CRT >
2 sec

ECG 12 lead: sinus rhythm, HR 88 bpm, RAD,

ischemic inferolateral wall , old myocardial
infarction anteroseptal, suggestive LM
disease, AV block grade 1, LVH

RBG 111 mg/dl

A:
Post Cardiac Arrest
Shock Cardiogenic
NSTE ACS Very High Risk
Hypertensive Heart disease
 Elektrocardiography 10/2/2021 ROSC

• Sinus rhythm, HR 88 bpm, Regular, axis 99, PR interval 0,24 s, ST elevation AVR, Q pahtologic
V1-V3, ST depression I,II, AVF, V5-V6, S at V3 + R at aVL >20 mm
• Conclusion : Sinus rhythm, HR 88 bpm, RAD, ischemic inferolateral wall, Old Myocardial
Infarction anteroseptal wall, suggestive Left Main disease, AV block grade 1, LVH
Echo bedside 10/2/2021
Echo bedside 10/2/2021
Time Follow up Management
10/2/21 S: unconsciousness Sulfas atropin 2 amp/intravenous
00.40
O: E1M1V1
Monitor : sinus bradycardia HR 40 bpm
sinus bradycardia HR 40 bpm --> Sulfas
atropin 2 amp/intravenous

00.45 S: unconsciousness - CPR + epinephrine 3 amp --> ROSC (-)

O: E1M1V1
Blood pressure unmeasurable, carotid pulse
is not palpable
THANK YOU