Morning Report

Cardiology Residents
Thursday, 25 Maret 2021

Team on duty:
dr. M. Hustiar Hakim
dr. Muhammad Rizki
dr. Nadia
dr. Tjut Farahiya Hadi
dr. Shahcoga Luthfi Y

Supervisor on duty in RSUZA Existing:

dr. Nurkhalis, Sp.JP-FIHA/dr. Aris Munandar, Sp.JP-FIHA

Supervisor on duty in Pinere:

dr. Sri Murdiati, Sp.JP (K)-FIHA/dr. Aris Munandar, Sp.JP-FIHA
25th Maret 2021
23.10 WIB
NO Identity Problem Assesment Therapy
1. Jufri, male, 53 yo, Patient is referred from Meuraxa 1. Post Respiratory Failure Therapi advice:
CM 1-02-75-35 hospital and has been diagnosed on ALO due to CHF, • Bedrest semifowler
with Respiratory failure on Acute CAD • O2 15 l/I
BP : 98/81mmHg • Sonde diet 6x200 cc
HR: 132 bpm Lung Oedem due to CHF, CAD 2. Severe pneumonia with
with HHD and SIRS Pneumonia. SIRS • Airway on ventilation
RR: 32 bpm mode CMV
T : 36.8 oC Patient has been hospitalized for 5 3. HHD
• Drip Vascon 0.1
SpO2 : 90% days in previous hospital. Patient 4. Hyperkalemia mcg/kg/min
presented to Meuraxa hospital with 5. CAD Post PCI in 2015 • Drip Propofol 30 mg/h
PF : pul : ves chief complaint of dyspneu that (no data)
(positive) ronkhi • IV Meropenem 1 gr b.i.d
(rough at entire occurred suddenly 2 hours before • IV Lasix 40 mg t.i.d
lung), wheezing admission. Dyspneu felt so bad so Laboratory Finding • IV Pantoprazole 40 mg
(positif) that patient couldn’t speak and Hb :17,8 b.i.d
diaphoresis. Chestpain before Eri : 6,0 • SC Lovenox 60 mg b.i.d
ECG: sinus dyspneu is denied. Dyspneu was Ht :54 • Nebule Ventolin 1 resp
tachycardia, qrs precipitated by activity. Leuko : 8,6 t.i.d
rate 147 bpm, • Clopidogrel 75 mg o.d
normoaxis, LVH Trombo : 164
Patient with hypertension since 5 Net. Seg : 78 • Atorvastatin 40 mg o.d
• NAC 400 mg t.i.d
RO :Lungs: years ago and unwell controlled. Limfosit : 17
• IV Ca gluconate 1 g
Increasing Patient also had been performed NLR :4,5 extra
broncovascular PCI and installed 2 stent DES in Ur :50
markings at left
Planning:
coronary artery. Cr : 1,40 1. Complete risk factor
side lung
eGFR : 57 ml/min/1,73 m2 laboratory test
Heart: CTR 75 %,
flattening of History of medication is Na : 151 2. CXR Cito bed
cardiac waist, right furosemide, aspilet, clopidogrel, K : 5,90 3. Echocardiography
atrial enlargement, simvastatin, omeprazole and Cl : 113 4. ICCU inpatient
right ventricle inpepsa. RBG : 278
enlargement. Trop T : <0,04
Jufri, male, 53 yo, CM 1-02-75-35

ECG : sinus tachycardia, qrs rate 147 bpm, normoaxis, LVH voltage criteria
Jufri, male, 53 yo, CM 1-02-75-35

AP Presentation
Interpretation:
Trachea : medial
Soft tissue: swelling (-)
Bones: fractures (-),
normal intercostal space
Lungs: Increasing broncovascular
markings at left side lung
Heart: CTR 75 %, flattening of
cardiac waist, right atrial
enlargement, right ventricle
enlargement.
Conclusion : Pneumonia and
Cardiomegaly
QUICK LOOK ECHOCARDIOGRAPHY
Jufri, male, 53 yo, CM 1-02-75-35
QUICK LOOK ECHOCARDIOGRAPHY
Jufri, male, 53 yo, CM 1-02-75-35
QUICK LOOK ECHOCARDIOGRAPHY
Jufri, male, 53 yo, CM 1-02-75-35

Quick Look Echo:

EF 20,7%, akinetic apical, another segments hypokinetic
TAPSE 1,15 cm
CO: 3,32 ml/min, SVR 1882 dyne.sec.cm-5
IVC exp: 2.59 cm, insp: 1.08 cm, Est RAP: 20 mmHg
26th Maret 2021
01.10 WIB
NO Identity Problem Assesment Therapy
2. Satiman, Patient was referred from 1. Loss of • Bedrest
• Threeway
Male, 51 yo Meulaboh hospital with a chief
1-26-97-54 complaint of loss of consciousness
consciousness e.c • Sonde diet 6x200 cc, low
protein
since 2 days ago. Previously acidosis • O2 NRM 12 l/m
• IV Ca Gluconas 1 resp
Cardiology patient was complain of swollen in respiratory (extra)
the extremity since 2 weeks ago. 2. Acute Right Heart • Nebu Ventolin 1 resp
Pf : at normal limit The patient also felt shortness of (extra)
breath, and chest pain when doing Failure due to • Bolus Insulin (novorapid)
ECG : 10 iu + dex 40% 2 flc
Sinus Rhytm, QRS heavy activities and reduced with Pulmonary (extra)
Rate 113 x/m, taking rest. Chest pain is not Hypertension • IV Furosemide 20 mg b.i.d
normoaxis, RBBB, accompanied by cold sweat, • IV Ceftriaxon 1 gr b.id
RVH RAE, poor R nausea, and vomitus. Patient had a
3. AKI Stage III pre- • Nebu Combivent 1 resp/ 6
progression hr
history of difficult sleep in a flat renal • N-Acetylsistein 600 mg
Rontgent : CTR position. 4. Pneumonia (CAP) t.i.d
60%, with apex Bicnat 500 mg t.i.d
(cardiomegaly) 5. Hyperkalemia •
History of hypertension and DM,
also stroke was denied by the Laboratory Finding Planning :
patient. • Treated in ICCU/HCU
Hb : 15,6 • Consult to Pulmonology, &
Ht : 53 Internist
History of taking medicine: Eri : 5,7 Check Lab : Pt, aPTT, INR,
•
Captopril 3x1/2 tab, Spironolacton Leuco : 17.800 this morning
1x25 mg, Notisil 1x1 tab. Tromb : 189.000 • Echocardiography
RBG : 119
BP : 104/58 mmHg Ur : 154
HR: 116 bpm (regularly) Cr : 2,20
RR: 24 times/minute Na : 137
T : 37 oC K : 5,80
SpO2 : 98 % with NRM 10 l/m Cl: 90
Satiman, Male, 51 yo 1-26-97-54

ECG :
Sinus Rhytm, QRS Rate 113 x/m, normoaxis, RBBB, RVH RAE.
Satiman, Male, 51 yo 1-26-97-54

AP Presentation
Interpretation:
Trachea : medial
Soft tissue: swelling (-)
Bones: fractures (-),
normal intercostal space
Lungs: normal broncovascular
markings
Heart: CTR 60 %
Conclusion : Cardiomegaly
QUICK LOOK ECHOCARDIOGRAPHY
Satiman, Male, 51 yo 1-26-97-54
QUICK LOOK ECHOCARDIOGRAPHY
Satiman, Male, 51 yo 1-26-97-54

Quicklook Echo:
EF 82%, dyskinetic septal wall, another segments normokinetics
TAPSE 1.6 cm, dilatated RA-RV
QUICK LOOK ECHOCARDIOGRAPHY
Satiman, Male, 51 yo 1-26-97-54
Patient Report
Patient Identity

• Name : Satiman

• Age : 51 y.o

• Race/ Ethnicity : Aceh

• Marital status : Married

• Religion : Islam

• Occupation : Enterpreuneur

• Date of Birth : 01/07/1970

• Medical Records : 1-26-97-54
 History Taking
• Chief complaint: loss of consciousness

Present illness history :

Patient was consulted from Meulaboh hospital with a chief complaint of loss of
consciousness since 2 days ago. Previously patient complaining swollen in the lower
extremity since 2 weeks. The patient also felt shortness of breath, and chest pain when
doing mild activities and reduced with taking rest. Chest pain is not accompanied by cold
sweat, nausea, and vomitus. Patient has a history of difficult sleep in a flat position since 2
weeks.

History of hypertension and DM, also stroke was denied by the patient.

History of Medications on previous hospital :

Drip Furosemide 2 cc/hr , Drip Dopamine 2 mg/KgBB/menit
Captopril 3x1/2 tab, Spironolacton 1x25 mg, Notisil 1x1 tab.
Physical Examination

• General appearance : Looked ill

• Alertness : Somnolen

• GCS : E2M4V3

• Vital Sign
• BP : 90/53 mmHg
• HR: 84 bpm (regularly)
• RR: 20 times/minute
• T : 36,1 oC
• SpO2 : 98 % with NRM 12 l/m
Head examination
Head Inspection : Normocephali
Palpation : Pain on palpation (-)
Hair Inspection : Black-white hair
Eyes Inspection : swelling on the eyelid (-), pale on conjunctiva (-/-), icteric (-),
nodul (-), xantelasma (-/-)
Face Inspection : symmetrical, swelling (-)
Skin Inspection : yellowish (-)
Ears Inspection : no deformity
Palpation: pain on palpation of tragus (-)
Nose and Inspection : normal shape of nose
paranasal Palpation: pain on palpation (-)
sinuses
Lips Inspection : asymmetrical (-), pale (-), cyanosis (-), swelling (-), dryness (-),
Mouth & Inspection : stomatitis (-), pale (-), looks wet (+), sub lingual icteric (-)
Tongue
Teeth Inspection : dentures (-), caries (-)
Neck Examination
Jugular Vein Pressure R+5 cm H2O
Thyroid Gland Inspection : enlargement (-)
Palpation : no sign of enlargement of thyroid glands
Lymph node Inspection : enlargement of lymph node (-)
Palpation : (preaurikular, postauricular, oksipital,
tonsilar, submandibular, submental, superficial cervical
posterior cervical, deep cervical
Unpalpable
Chest Examination
Inspection No deformity, symmetrical on respiration, unseen ictus cordis
Palpation Pain on palpation (-). Stem fremikus (N/N)
Ictus cordis palpable on 2 cm lateral of left LMCS 5th intercostal, thrill,
heaving, lifting, tapping (-)
Percussion sonor (+/+)
Left border : 2 cm lateral of left LMCS 5th intercostal
Upper border: 3rd intercostal of left Mid Clavicula
Right border: 4th intercostal of right parasternal
Auscultation Breath sounds: vesicular (+/+)
Additional breath sound : ronkhi (-),wheezing (-/-)
Aorta : 1st HS < 2nd HS , murmur (-), splitting of S2
Pulmonal: 1st HS < 2nd HS , murmur (-)
Trikuspidal : 1st HS < 2nd HS , murmur (-)
Mitral : 1st HS < 2nd HS , murmur (-)
 Abdomen
Inspection Distended

Auscultation Normal bowel sound

Percussion Normal limit

Palpation Pain on palpation (-), Hepar : 2 cm below arcus

costae

Genital Did not perform

Ekstremities
Superior Motoric : 5555/5555 Edema : -/-
Ekstremities Flapping tremor (-)
Cold and clammy (-)
cyanosis (-)

Inferior Motoric : 5555/5555 Edema : +/+,

Ekstremities pitting grade 2
cyanosis (-)
Electrocardiography

ECG Interpretation
Callibration : 10 mm/mV ECG:
Rhytm : Sinus Sinus Rhytm, QRS Rate 113 x/m,
Heart Rate : 113 bpm normoaxis, LAE, RVH, persisten S wave
Axis : Normoaxis
P Wave : RVH
PR interval : 0,20 s
QRS : 0.12 s,
ST deviation : none
T inverted : none
Satiman, Male, 51 yo 1-26-97-54

AP Presentation
Interpretation:
Trachea : medial
Soft tissue: swelling (-)
Bones: fractures (-),
normal intercostal space
Lungs: normal broncovascular
markings
Heart: CTR 60 %
Conclusion : Cardiomegaly
QUICK LOOK ECHOCARDIOGRAPHY
Satiman, Male, 51 yo 1-26-97-54
QUICK LOOK ECHOCARDIOGRAPHY
Satiman, Male, 51 yo 1-26-97-54

Quicklook Echo:
EF 82%, dyskinetic septal wall, another segments normokinetics
TAPSE 1.6 cm, dilatated RA-RV, RV>LV, Mc Connel sign (-), IAS intact
QUICK LOOK ECHOCARDIOGRAPHY
Satiman, Male, 51 yo 1-26-97-54
 Temuan Laboratorium
Parameter Hasil Nilai Rujukan

Hemoglobin 15,8 14.0 – 17.0 Parameter Hasil Nilai Rujukan

Hematokrit 53 45 - 55 Limfosit 2 20 - 40
Eritrosit 5,7 4.8 – 6.1 Neutrofil segmen 85 50 - 70
Trombosit 189 150 - 450 NLR 44,5 <3,5
Leukosit 17,8 4.5 – 10.5
Parameter Hasil Nilai Rujukan
MCV 94 80 - 100
MCH 28 27 - 31 pH 7,240 7,35-7,45
MCHC 30 32 - 36 pCO2 103,70 35-45

RBG 119 < 200 pO2 160 80-100

Natrium 137 132 - 146 HCO3 44,8 23-38

Kalium 5,80 3.7 – 5.4 BE 11,9 (-2) (+2)

Klorida 90 98 - 106 spO2 98,3 95-100

Ureum 154 13 - 43
Creatinin 2,20 0.67 – 1.17
eGFR 33 ml/min/1,73 >90 ml/min/1,73
m2
m2
Sardjito Score : 9

Revised Geneva score: 1 (PE unlikely)

Diagnoses

1. Loss of consciousness e.c respiratory acidosis due to Pneumonia dd PH

2. Right Heart Failure ec High probability PH type 3 dd type 1
3. AKI Stage 3 pre-renal
4. Pneumonia (CAP)
5. Hyperkalemia
Therapy
• Bedrest
• Threeway
• Sonde diet 6x200 cc, low protein
• O2 NRM 12 l/m
• IV Ca Gluconas 1 resp (extra)
• Nebu Ventolin 1 resp (extra)
• Bolus Insulin (novorapid) 10 iu + dex 40% 2 flc (extra)
• IV Furosemide 20 mg b.i.d
• IV Ceftriaxon 1 gr b.id
• Nebu Combivent 1 resp/ 6 hr
• N-Acetylsistein 600 mg t.i.d
• Bicnat 500 mg t.i.d
Planning

• ICCU inpatient
• Consult to Pulmonology
• Check Lab : PT, aPTT, INR
• Echocardiography
 Follow Up 29/3/2021
Problem Assesment Therapy
1. Loss of consciousness e.c IV Furosemide 20 mg b.i.d
S/ improved in IV Ceftriaxon 1 gr b.id
respiratory acidosis due Nebu Combivent 1 resp/ 6 hr
consciousness, dyspneu not to Pneumonia N-Acetylsistein 600 mg t.i.d
observed 2. Right Heart Failure ec Bicnat 500 mg t.i.d
High probability PH Sc Enoxaparin 60 mg b.i.d
O/
group 3 dd group1 P/ Echocardiography
GCS: 14 •
3. AKI Stage 3 pre-renal
BP : 118/66 mmHg 4. Pneumonia (CAP)
5. Hyperkalemia
HR : 88 bpm
(corrected)
RR : breath/min
T : 36.5 C
SpO2 : %

Pf:
Ext: pitting edema grade 1
Thank You