MORNING REPORT

Monday, February 20th 2017

COASS INCHARGE:
Rani Astari
Selwina Khony
Kevin Leonardo

CONSULENT : dr. Iqbal Lahmadi Sp.PD

 Total patients :
ER (AU : BPJS : U: )
Ward (AU : BPJS : U: )
Death case : 1 patient
Interna :
Melati ward patients
Kenanga ward 13 patients
Total patients from 15 pm 04 am :
3 New-in patients
Male/49 yo/EH
Male/ yo /CKD + DM type 2
Female/25 yo/DF
 Summary of Data Base
Male/40 y.o
Chief complaint: left chest pain
Patient suffered left chest pain radiated to the left back
and left arm in the last 5 hours before admission. The
pain was accompanied with nausea, vomit (5x), cold
sweating and heartburn.
He had never diagnosed as diabetes and cardiovascular
disease before.
He had history of hypertension since 2014
 Physical Examination
BP = 140/100 mmHg HR = 80x, reguler RR = 21 T ax 36,7 C
SpO2 : 97%

General appearance : looked severe ill GCS : E3 V5 M6

Head anemic (-/-) icteric (-/-)

Neck wnl

Thorax
Cor wnl

Pulmo Simetric, SF D = S SS v v Rh - - Wh - -
SS v v - - - -
DS v v - + - -

Abdomen Flat, Soefl, Hepatomegaly (-), bowel sounds (+), skin turgor normal (+),
epigastric pain (+)

Extremities Oedema -/-, CRT 2s

 LABORATORY FINDING
Lab, 20 Feb 2017 Value Lab Value

Leukocyte 18.100 3500-10000/L SGOT 21 11-40 U/L

Eritrocyte 5,90 3,50-5,50
Haemoglobin 17,4 11,0-16,5g/dl SGPT 25 10-41 U/L
MCV 90,5 75-100 fl Albumin 3.5-5.5 g/dl

MCH 29,6 25-35 pq

Trombocyte 150000-390000/L
254.000
Hematocrite 53,4 35-55
RBS 81 (<200)mg/dL
Ureum 10-50g/dL Na 136-145 mmol/L
Creatinine 0,7-1,5mg/dL K 3.5-5.0 mmol/L
CPK 10-80 U/L
Cl 98-106 mmol/L
CKMB 2-10 U/L:

Troponin I - ng/ml
 ECG
Synus rhythm, HR 100x/mnt
Frontal axis: Normal
Horisontal axis: Clockwise
PR interval: 0,12
QRS comp: 0,06
QT interval: 0,32
T inverted at II, III, aVF
Conclusion; sinus rhythm HR 100 with T inverted with IMA
inferior
CUE AND PROBLEM INITIAL PLANNING PLANNING THERAPY P mon
CLUE LIST DIAGNOSE DIAGNOSE

Male, 40y.o 1. IMA Coronary Total bedrest, semi VS,

Left chest pain Angiography fowler position cardiac
inferor
Fasting enzym
onset 5 hours Chest Pain Foley catether
BP 140/100 Killip class O2 NC 4 lpm
ECG
IV IVFD NS 20dpm
Nausea and Vagal Relux Ranitidin 2x50mg (iv)
vomitting Morfin2-4 mg iv
Nitrat SL
ECG: T-inverted Arixtra 1x1 vial (2,5
(II,III,AVF) mg) sc 3 days
Clopidogrel 4x75 mg
tab
Aspilet 4x80mg p.o, 1x
8omg p.o
Bisoprolol 1x 2,5mg
Valsartan 1x 80 mg
Simvastatin 1x20mg
Diazepam 2x5mg
Laxadin 3x15cc
 KILLIP
Class Definition Mortality (%)
I No congestion heart failure sign 6
II + S3 and / or basiler rales 17
III Pulmonary edema 30-40
IV Cardiogenic shock 60-80
On the left an overview of the
coronary arteries in the anterior
projection.

Left Main or left coronary artery (LCA)

Left anterior descending (LAD)
diagonal branches (D1, D2)
Septal branches
Circumflex (Cx)
Marginal branches (M1,M2)

Right coronary artery

Acute marginal branch (AM)
AV node branch
Posterior descending artery (PDA)
 On the left an overview of the
coronary arteries in the right
anterior oblique projection.

Left Main or left coronary artery (LCA)

Left anterior descending (LAD)
diagonal branches (D1, D2)
septal branches
Circumflex (Cx)
Marginal branches (M1,M2)
Right coronary artery
Acute marginal branch (AM)
AV node branch
Posterior descending artery (PDA)