dr.

Satiti

MEDICAL CONSULTATION
from Cardiology Department
Patient with
1. Stemi inferoposterior killip II post PCI
2. DM type 2 Hyperglycemia
3. HT stage 1
4. HF stage C Fc III dt CAD+HHF
5. AKI stage 1 dd CKD stge 3

The aim of consultation :

Management of Hyperglycemia
 Summary of Database

Mrs S/48yo/CVCU
heteroanamnesa
History of Present Illness:
- Patients is treated by Cardiology Department with inferoposterior Stemi post PCI
- Previously, the patient complained of shortness of breath, especially during light activity
and improved with rest, and intermittent chest pain
- The patient was treated at Baptist Hospital for 3 days and was said to have diabetes, a
history of administering insulin Lantus 1x12 IU bedtime and Apidra 3x4 IU Premeal
- History of Hypertension (+) for 10 years, not taking medication regularly
- polydipsia (-), polyuria (-), polyphagia (-), weight loss (-).
 Summary of Database
Past Medical History:
Theres no remarkable past medical history
Family History:
His mother had been diagnosed with Hypertension
Social History:
She lives with her husband and 3 children. according to her husband, she likes to eat with
santan and satay
Review of System:
Urination and defecation within normal limit
 Physical Examination
General appearance looked moderately ill Sat O2 99% NC 4 lpm
GCS 456 BB : 60 kg TB 166 cm BMI 21,8 kg/m² UOP : 2000cc/24 jam ~ 1.28 cc/kgbw/our
BP: 140/60 mmHg PR 94 bpm regular strong RR 20 tpm Tax 36,7 oC
Head Anemic Conjuctiva (-),jvp R+5cm H20
Neck JVP R+ 2 cmH20 30 degrees, enlargement lymph nodes (-)
Chest Symmetrical, retraction (-)
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)
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)

Abdomen Flat, soefl, Bowel Sound (+) normal,

Liver/ liver span 8 cm Lien/ traubes Tympany

Extremities Warm (+); CRT <2 sec ; Pitting Edema Lower Extrimites (-/-)
 Laboratory Findings (29/3/2022)
LAB VALUE NORMAL LAB VALUE NORMAL
Hemoglobine 10,9 11,4 - 15,1 g/dl Ureum 69,1 20-40 mg/dL
Leucocyte 17.350 4.700 – 11.300 /µL Creatinine 1,76 <1,2 mg/dL
HCT 33,3% 38 - 42% GFR 33,7 >90 mL/min/1.73 m2
Thrombocyte 390.000 142.000 – 424.000 /µL Natrium 139 136-145 mmol/L
MCV 26,5 80-93 fl Kalium 3,54 3,5-5,0 mmol/L
MCH 32,7 27-31 pg Chlorida 102 98-106 mmol/L
SGOT 23 0-40 U/L RBS (21.00) 133
SGPT 44 0-41 U/L Troponin I 11,9
Procalcitonin 0,84 CKMB 48
HbA1C (RS Baptis 9,6% <6,5%
ELECTROCARDIOGRAPHY 29/3/2022
 Electrocardiography (29/3/2022)
 Sinus rhythm HR 100 bpm
 Frontal Axis : Normal
 Horizontal Axis : Normal
 P Wave : Normal
 PR interval : 0.13”
 QRS complex : 0.08”
 Q wave : Normal
 QT interval : 0.36”
 ST Segmen : Elevated II, III, AvF ; Depresed V1, V2
 T Wave : inverted at V2-V3

Conclusion : Sinus takikardia + HR 100 bpm + Stemi Inferior

Chest X-Ray (29/3/22)
 Chest X-Ray (30/03/2021)
• AP position, symmetric, enough KV, enough inspiration
• Soft tissue was thin and bone was normal
• Trachea in the middle
• Hemidiaphragm D and S was dome-shaped
• Phrenico-costalis angle D and S was sharp
• Pulmo: bronchovesicular pattern was normal
• Cor: site N, size CTR 69%, shape N, elongation aorta (-), cardiac
waist (+)

Conclusion: Cardiomegaly
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mrs. S / 48 yo/ CVCU Bed 7 1. STEMI - - Non Pharmacology Monitoring

Subjective Inferior Killip II - Bed Rest - Subyektif
- Pastient treated by Cardiology Dept with Post PCI - Post PCI - Obyektif
Typical chest pain symptom
- Diagnosed with STEMI Inferior - Shock
- History uncontrolled HT Pharmacology by
Cardiology departement Education
Objective - PO ISDN 5 mg k/p - Education
VAS : 3/10 - PO Ticagrelor 2x90 mg regarding
BP : 140/60
- PO Aspilet 1x80 mg the disease
Laboratory Result - PO Atorvastatin 1x40 mg and planning
Trop i: 11,9 ug/L CKMB: 48U/L CRP: 26,56 - PO Captopril 3x6,25 mg therapy
- PO Bisoprolol 1x1,25 mg - Routinely
EKG 29/03/2021 Consume
Sinus takikardia dengan stemi inferior medication
CXR and
Cardiomegaly regularly
control
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mrs. S / 48 yo/ CVCU Bed 7 2. DM type 2 - - Non Pharmacology Monitoring

normoweight - DM Diet 1800 kkal ~ - Subyektif
Subjective normoglycemi BROCA (Carb 55%, - Obyektif
- Patient was diagnosed with DM 3 days ago in
Baptist Hospital and patient use insulin Lantus a protein 25%, Fat 20%) - RBG,
1x12 IU and Apidra 3x4 IU before eating FBG/2hppbg
Pharmacology - UL
Objective - SC Lantus 0-12 iu - Lipid
BMI : 21,4 kg/m - SC Apidra 3x4 iu Profile
Laboratory Result
RBG : 133 mg/dL
HbA1c : 9,6 % Education
- Education
regarding
the disease
and planning
therapy
- Routinely
Consume
medication
and
regularly
control to
achieve
targeted
Glucose
level
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mrs. S / 48 yo/ CVCU Bed 7 3. HF stage C 3.1 dt Echochar Non Pharmacology Monitoring
Fc III CAD diograph - Bed Rest - Subyektif
Subjective 3.2 y
DOE (+), PND (+), Ortopneu (-) - Fluid restriction - Obyektif
HHF - SOB, SpO2
Objective Pharmacology
BP : 140/60 - PO Captopril 3x6,25 mg Education
K/L JVP R+5cm H2O - PO Bisoprolol 1x1,25 - Education
Cor : ictus palpable at ics V 2cm lateral MCL mg regarding the
sinistra - PO Furosemid 1x40mg disease and
Laboratory Result planning
Trop i: 11,9 ug/L CKMB: 48U/L therapy
- Routinely
CXR : Cardiomegaly Consume
ECG : Sinus takikardia + HR 100 bpm + Stemi medication
Inferior
and regularly
control
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL Idx PDx PTx PMo&Ed

Mrs. S / 48 yo/ CVCU Bed 7 4. HT stage 1 4.1 - Non Pharmacology

Primay Fundusco - Low Sodium Diet < 2 Monitoring
Subjective Hypert py gr/day - Subyektif
- History of HT Uncontrolled since 10 years ago
ension - Obyektif
Objective 4.2 Pharmacology
- BP : 140/60 mmHg Second - PO Captopril 3x6,25 mg Education
ay - PO Bisoprolol 1x1,25 mg - Education
Laboratory Result Hypert regarding
CXR : Cardiomegaly ensiom the disease
ECG : Sinus takikardia + HR 100 bpm + Stemi and planning
Inferior therapy
- Routinely
Consume
medication
and
regularly
control
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mrs. S / 42 yo/ CVCU bed 7 5. AKI stage 1 DKD USG Non Pharmacology
CRS Abdomen -Diet 1800 kkal/day protein Monitoring
Subjective Type 1 0,6-0,8 g/kggbb/day - Subyektif
- History of HT Uncontrolled since 10 years ago
- STEMI currently - Obyektif
- Diagnosed with DM since 3 days ago Pharmacology Ur/Cr serial
- Adequate fluid Intake
Objective - Controlled blood Education
- BP : 140/60 mmHg pressure and Cardiac - Education
- UOP : 1,2cc/kgBB/day problem regarding
Laboratory Result the disease
Ur/Cr: 69,1/1,76 and planning
BUN/Cr ratio 18 ~renal/post renal type therapy
eGFR: 33,67 mL/mnt - Routinely
Consume
medication
and
regularly
control
 TREATMENT GIVEN
BY DEPARTMENT

Therapy from Cardilogy department

Non Pharmacology
-Post PCI
-Fluid restriction 2000cc/24 hour (Included oral Intake)
-HCHP diet 1800 ccal/day

-Non Pharmacology
-IVFD NS 500cc/24 h
-PO ISDN 5mg PO k/p
-PO Ticagrelor 2x90 mg
-PO Aspilet 1x80 mg
-PO Atorvastatin 1x40 mg
-PO Captopril 3x6,25 mg
-PO Bisoprolol 1x1,25 mg
 WE SUGGEST THIS PATIENT

PDx and PTx :

- Equal Fluid Balance
- Bed Rest
- DM Diet 1800 kkal ~ BROCA (Carb 55%, protein 25%, Fat 20%)
- SC Lantus 0-12 iu
- SC Apidra 3x4 iu  postpone waiting for Fbg/2hppbg
- Lipid Profile, UL

P.Mo:

- Monitoring FBG, RBG, After meal BG, Ur/Cr per 24 hours.

Patient will be treated collaborative care with Endocrinology division if colleague and patient give
consent.
Condition Patient this Morning:

• GCS : 456
• BP : 110/60mmHg
• RR : 20
• Tax : 36,4
• SpO2 : 99% NC 2lpm
THANK YOU