Morning Report

Wednesday, February 19th 2014

Coass in charge: nur,ratih
Ward : cvcu
Prof.Dr.dr.Djanggan, SpJK (K)
Consultant on duty :
MR consultant:


SUMMARY OF DATABASE
Mr Kuat / 52 y.o

Chief Complaint : Chest pain

Male/52yo/W.CVCU
Chief complaint: Chest pain
Patient has been suffering from chest pain abrupt onset at home, after he come
back from work (30 minute before arrived at ER), he couldnt describe the location and
its about 20 minutes and happened continously. The chest pain was heavy-like
sensation, excessive of cold sweating, and not relieve with rest but there was no
complaint about shortness of breath. He said he didnt took drugs for 3 days before
admission because he said his blood pressure is normal.
After he felt chest pain, he took drugs: ASA 80 mg and CPG 75 mg at home, and his
family imidiately brought him to RSSA, at the ER, after perform ECG and laboratory he was
given ASA 3 tablet and CPG 3 tablet again from the doctor.
History has previous typical chest pain twice, at 2005 admitted in CVCU for 8 days
and 2011 for 8 days
He had been diagnosed HT since 10 years ago, routinely control and took
medication (valsartan 1x80, ASA 1x80, Simvastatin 1x20mg), highest BP about 160/-
He is a active heavy smoker since youth (12 bar/day) and stopped since 2005 after
felt chest pain.
He is a pharmacist at RSSA, have 2 children and never drink alcohol.


PHYSICAL EXAMINATION-CVCU
General
appearance
Looks moderately ill
Vital sign BP 149/92 mmHg
HR 87tpm
RR 18 tpm
Head Pale conjungtiva -,Icteric-
Neck JVP R + 0 cmH2O at 30
o
Thorax :
Heart &Lung
Ictus invisible palpable at ICS V 1 cm lat MCL (S)
RHM SL D LHM as ictus
S1,2 normal , gallop (-) murmur (-)
Simetric, Rh - - W h - -
- - - -
- - - -
Abdomen Flat,bowel sound (+) normal, soefl, H/L unpalpable, liver span
8 cm, troube space tympany
Extremities Warm acral, Edema(-), Cyanosis (-)
LABORATORY FINDING
Lab value Normal
value
Lab Value Normal
value
Leuco 8.920 /L 3.500-10.000 CPK 108365 u/L 30-190
Hb 13.4 g/dl 11-16.5 CKMB 1951 u/L <25
Thrombo 262.000 /L 150-390.10
3
Trop I 0.01,3 Ng/ml Neg
PCV 39.2 % 35-50 Na 138 mmol/L 136-145
RBS 138 mg/dl <200 K 3.96 mmol/L 3,5-5
Ureum 27.0 mg/dl 10-50 Cl 109 mmol/L 98-105
Creatinin 1.26 mg/dl 0,7-1.5
SGOT 45 U/L 11-41
SGPT 16 U/L 10-41
ECG at ER at 18.00
0 Sinus rhyth, Heart rate 90 bpm
0 Frontal Axis : LAD
0 Horizontal Axis : normal
0 PR interval : 0.12
0 QRS complex : 0.08
0 QT interval : 0.40
0 ST elevation I, AVL
0 ST depresion III, AVF
0 Conclusion: sinus rhythm with heart rate 72 bpm, STEMI high
laterall wall,

CXR
0 AP position, symmetric, strong KV, less inspiration
0 Soft tissue thin, Bone normal
0 Trachea in the middlle
0 Hemidiaphragm D/S dome shape
0 Phrenico costalis angle D/S sharp
0 Pulmo D/S :normal
0 Cor: site N, size CTR 60%
Conclusion : less inspiration looks cardiomegaly

CUE AND CLUE PROBLEM LIST
INITIAL
DIAGNOSE
PLANING
DIAGNOSE
PLANNING THERAPY
PLANNING
MONITOR
1. Mr K/52 yo
Ax: chest pain since 5 pm
(30 minutes before
admission) heavy like
sensation, >20 minutes,
continuesly not relieved
with rest.
History HTN since >20
years poorly controlled,
Smoking since youth, quit
9 years ago
Family history
History hospitalized 2x
because of chest pain
PE : BP BP 150/90mmHg
HR 89tpm RR 18tpm
ECG : Sinus rhytm with ST
elevation I, AVL, ST
depression II, III, AVF
Lab :
CKMB 19 51
Trop I 0.0 1,3
1.STEMI high
lateral onset < 1
hour
TIMI score 1/14
KILLIP I GRACE
98
- Coronary
angiography
, Echo, Lipid
profile
O2 4 lpm NC
Bed rest
Semifowler position
Insert urine condom
catheter
Fluid balance 0/24h
IVFD NacL 0.9% 1500
cc/24 hours
Inf. Streptokinase no
stock
Inj. LMWH (enoxaparin )2
x 0.6 cc sc
Po.
ASA lx 80 mg
CPG 1 x 75 mg
Alprazolam 0-0-0.5mg
Simvastatin 0- 0- 20 mg
ISDN 3 x5 mg
Stool softener 3 x CI

S
VS
ECG
CUE AND CLUE PROBLEM LIST
INITIAL
DIAGNOSE
PLANING
DIAGNOSE
PLANNING THERAPY
PLANNING
MONITOR
2. Mr K/52 yo
Ax : history HTN known
since 20 years ago
Routionelly controlled
to cardiology
outpatient department
PE : BP 150/90mmHg

2.
Hypertension st
I (on treatment)

2.1 essential
2.2 secondary
As above
Valsartan 1x80mg
S
VS
Thank you