Morning Report

9 January 2015

dr. Niniek Burhan, SpPD-KPTI

Summary of Data Base

Mr. L/ 61 years old/Ward CVCU
HISTORY TAKING : autoanamnesis and heteroanamnesis
CHIEF COMPLAIN : chest pain
HISTORY OF PRESENT ILLNESS

Patient suffered from left sided chest pain since 7 hours before
admission, sharp pain like tearing, radiated to all area of the chest
and back, left arm and jaw, accompanied by shortness of breath,
and didnt relieve by rest. He also felt nausea upper abdominal
pain and cold sweating. He was admitted to Bangil hospital then
reffered to RSSA.

Previously, he never felt chest pain.

He had hypertension known since a year ago, around 180/100

mmHg, did not took medication.

PAST MEDICAL HISTORY

FAMILY HISTORY
SOCIAL HISTORY
He is motor pedicab driver

ABNORMAL PHYSICAL EXAMINATION

General Appearance: looked moderately ill

Looked normoweight

GCS: 4.5.6

BP: 150/90 mmHg

Head

Anaemic conjunctiva (-), icteric (-), sianosis (-)

Neck

JVP: R + 3 cm H2O in 30 position, lymph node enlargement (-/-)

Chest

PR: 82 times/minute

RR: 28 times/minute

Wall

Within normal limit

Heart

Ictus visible, palpable at ICS VI 2 cm lateral MCL S

Left heart margin at ictus, right heart margin at parasternal line D
Heart rate 82 times/minute, regular
S1S2 single, murmur sistolic grade 3/6 radiated to axila

Lung

Symmetry, stem fremitus D=S, rales (-), wheezing (-)

Abdomen

Flat, bowel sound normal, liver span 10 cm, Traubes space tympani

Extremities

Warm, no edema

Tax: 36,2C

LABORATORY RESULTS
Laboratory
Hb
Leucocyte
Hematocrit
Thrombocyte
MCV
MCH
MCHC
Differential
count
SGOT

Result
12
9,790
36,1
215.000
88,5
29,4
33,2
0,3/0,1/81,4/13,1/5,
1
103

Normal Value
13,4-17,7
4.300-10.300
40-47
142.000-424.000
80-93
27-31
32-36
0-4/0-1/51-67/2533/2-5
0-32

Unit
g/dL
/L
%
/L
fL
pg
g/dL
%

31

0-32

U/L

CK-NAC

1.008 1.719

39-308

U/L

CK-MB

184 306

7-25

U/L

2 7,5
34,6

<1,0
16,6-48,5

g/L
mg/dL

Creatinine

1,17

<1,2

mg/dL

RBS

118

<200

mg/dL

SGPT

Troponin
Ureum

U/L

Laboratory
Natrium

Result
134

Normal Value
136-145

Unit
mmol/L

Kalium

3,6

3,5-5,0

mmol/L

Chloride

117
109

98-106

mmol/L

<200

mg/dL

11,2
27,1
0,94

11,5-11,8
27,4-28,6
0,8-1,3

second
second

Random blood
gluc
PPT
APTT
INR

Chest X ray

Electrocardiography 10.30

KILLIP Classification
CLASS

DEFINITION

MORTALITY (%)

No congestive heart
failure signs

II

17

III

+ S3 and/or basilar
rales
Pulmonary edema

30-40

IV

Cardiogenic shock

60-80

GRACE ( global registry of acute coronary events ) SCORE

GRACE ( global registry of acute coronary events ) SCORE

Score :
140

Problem Oriented Medical Record

Cue and Clue
Male/61 years old
Anamnesis:
Thypical chest pain
since 6 hours before
admission, didnt
subsided
Physical examination:
BP:150/90 mmHg
PR: 82 bpm
RR: 28x/mnt
Laboratory:
Troponin I: 2 mcg/L
CKNAC: 1.008 U/L
CKMB: 184 U/L
SGOT: 103 U/L
Electrocardiography:
ST elevation at V3 and
aVF
Chest X ray:
Cardiomegaly

Problem List
1. STEMI
inferior
onset >12
hours
Killip I, TIMI 3,
GRACE 140

Initial
Diagno
sis

Planning
Diagnosis

Planning Therapy

Planning
Monitoring

Bed rest semifowler position

Coronary
angiograph Fasting until symptoms subsided and start
y
fluid diet 6x200 mL

Monitoring:
Subjective,
Vital sign,
Troponin I, CKOxygen 4 litres/minute nasal canule
NAC, CKMB, ECG,
Infusion NacL 0,9% 500 mL/24 hours with -500 echocardiograph
mL fluid balance.
y
Streptokinase 1,5 million unit in 500 mL within APTT
30 minutes
Enoxaparin 2x0,6 mL subcutaneous
ASA loading 320 mg, maintenance 1x80 mg
tablet
Clopidogrel loading 300mg, maintenance 1x75
mg tablet
ISDN 3 x5 mg
Alprazolam 1x0,5 mg tablet
Simvastatin 1x20 mg tablet
Laxadine 3xCI suspension
Captopril 3x12,5 mg tablet
Bisoprolol 1x2,5 mg
(Reference: American Heart Association STEMI
Guideline, 2013)

Education:
Low fat, low
sodium salt diet

Problem Oriented Medical Record

Cue and Clue
Male/61 years old

Problem List
2. Hypertension
stage 1

Anamnesis:
Long standing
hypertension

Planning
Diagnosis

Initial Diagnosis
2.1 Primary
Hypertension
2.2 Secondary
hypertension

Planning Therapy
Low salt diet
Captopril 3x12,5 mg
tablet

Physical examination:
BP: 150/90 mmHg

Female/64 years old

Anamnesis:
Long standing
hypertension, shortness
of breath in hard
activities and lying
down.
Physical examination:
Ictus palpable ICS VI
2cm lat MCL S
Laboratory:
Ureum: 52,9 mg/dL
Creatinin: 1,67 mg/dL
Chest X ray:
Cardiomegaly
Electrocardiography:
STEMI anteroextensive

Planning Monitoring
Monitoring:
Subjective
Vital sign
Ureum, creatinin
Urine production
Education:
Low salt diet
Fluid restriction

3. Heart failure
stage C functional
class II

3.1
Hypertensive
heart disease
3.2 Coronary
artery disease

Echocardiograp Low salt diet

Fluid restriction
hy
Captopril 3x12,5 mg
tablet
(Reference: American
Heart Association
Guideline for Heart
Failure, 2013)

Monitoring:
Subjective
Vital sign
Echocardiography
Urine production
Education:
Low salt diet
Fluid restriction

Condition this morning

GCS 456, chest pain was reduced

BP : 129/86mmHg
PR : 70bpm
RR : 22tpm
UOP : 300cc/9 hours

THANK YOU