Morning Report

18 nov, 2016
Dept of internal medicine
j25
 OB Interna
Nama Diagnosis Ruangan
Tn marjan 60 th IMA gone
Ny riyati DM type II + dekom cordis+hipokalemia Marwah 3.1
Nn nizatul DHF zam zam
17
Ny lilik dyspepsia RJ
Ny anis dyspepsia RJ

Ny suharti dyspepsia RJ

Ny bidayah DM, takikardi, hiperensi esensial Marwah

11.3
Identity
Name : Mr M
Age : 70 years old
Occupation : -
Address :lamongan
Admission : 17 nov 2016 at 22.00
Chief Complaint

chest pain
Present history

patients complaint chest pain since 11 hours before

admission to hospital . the chest pain is penetrate until to
behind his back and to the left arm. Chest pain is felt
suddenly when the patient was outside the house.
Shortness of breath + . The pain is severe chest pain until
patient have sweats. Patient have been brought to RSMB
and has been given HES and dopamine. Nausea -,
vomiting -, stomach pain -, headache -. Appetite is norml.
Defecate and pee is normal. Patients smoking more than
30 years.
Past history of Illness

HT 5 years and uncontrolled

DM 10 years and uncontrolled

Family history

No familial related
Social history

Patients smoke more than 30years

Vital Signs
Pulse
85x/min, low
BP
64/44mmHg
Temp
36C
RR
40x/min
GENERAL STATUS
General condition : weak
Awareness : compos mentis, agitation
GCS : 456
H/N : a -/i-/c-/d+
 Thorax
Inspection
Symmetrical, retraction -
Palpation
Fremitus N, thrill (-)
Percussion
Lungs: sonor +/+
Cor: N
Auscultation
Lungs: ves /ves, rh -/-, wh +/+
Cor: S1 S2 single, mur -, gall-
 Abdomen
Inspection
flat
Auscultation
Met -, BU + N
- Palpation
Tenderness
Liver/Spleen ttb
Percussion
tymphany
 Extremities
Inspection
Clubbing fingers (-), icteric (-), cyanosis (+),
anemis (-)
Palpation
CWP
CLUE AND CUE
male 70 years old
Chest pain penetrate until his back dan his arm
Cold sweat
DM and HT uncontrolled
Smooking >30 years
Assesment
IMA
Planning Diagnose
EKG
Thorax foto
BGA
DL
 Laboratory Findings
Eritrosit 4.90 ( 3.80 - 5.30 )
Hemoglobin13.4( 14.0-18.0 )
Laju Endap Darah 1 8 ( 0 - 1 )
Laju Endap Darah 2 16 ( 1 - 5 )
.Limposit 5.3 ( 25.0 - 33.0 )
Basofil 4.7 ( 0.0 - 1.0 )
Eosinopil 0.3 ( 1.0 - 2.0 )
Hematokrit 41.0( 40.0 - 54.0 )
Lekosit 17.3 ( 4.0 - 11.0 ))
(MCH 27.30 ( 28.00 - 36.00 )
MCHC 32.70( 31.00 - 37.00 )
MCV 83.70 ( 87.00 - 100.00 )
Monosit 4.5 ( 3.0 - 7.0 )
MPV 4 ( 5 - 10 )
Neutropil 85.2 ( 49.0 - 67.0 )
RDW 11 ( 10 - 16 )
Trombosit 162 ( 150 - 450 )
Clorida Serum 102 ( 70 - 108 )
Kalium Serum 6.1 ( 3.6 - 5.5 )
Natrium Serum 131 ( 135 - 155 )
Serum Creatinin 2.5 ( 0.8 - 1.5 )
Urea 72 ( 10 - 50 )
Uric Acid 7.6 ( 3.1 - 7.9 )
Cholesterol 160 ( 125 - 240 )
Trigliserida 63 ( 0 - 200 )
Gula Darah Acak 422 ( )
Throponin I 2.63 ( 0.00 - 0.01 )
CKMB Massa 107.7 ( 0.0 - 5.1 )
.Clorida 92 ( )
.Kalium 5.88 ( 3.50 - 5.10 )
.Natrium 136 ( 136 - 145 )
Be -20.0 ( )
Beecf -22.4 ( )
cthb 15.5 ( )
HCO3 10.3 ( 22.0 - 26.0 )
Hct 46 ( )
PCO2 16.3 ( 35.0 - 48.0 )
pH 7.178 ( 7.350 - 7.450 )
PO2 88.3 ( 83.0 - 108.0 )
SO2 94.8 ( 94.0 - 98.0 )
Ro Thorax
EKG
RSML
 Planning Therapy
DK residu 50cc
O2 NRM 10 lpm
inj santagesic 3x1gr
inj panloc 2x40mg
pump N-epi mulai 3microkgbb/menit-->turun 2
microkgbb/menit-->turun 1 microkgbb/menit
pump Dobutamin 5micro/kgbb/menit
inj heparin bolus 4000IU-->lanjut pump
750cc/jam
inj ca gluconas 1 ampul-->inj insulin 3x8 IU--
>cek GDA+SE
PO:
asa loading 300mg-->1x100mg
clopidogrel loading 300mg-->1x75mg
PLANNING MONITORING
Vital Signs
GCS
Patients complaint
PLANNING EDUCATION
Explain to the patient and his family about
the disease, cause, stadium of the disease,
complication, intervention of the therapy and
prognosis.