Morning Report Wednesday, February 19th 2014

Coass in charge: nur,ratihWard : 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 painPatient has been suffering from chest pain abrupt onset at home, after he come back

from work (30 minute before arrived at ER), he couldn’t 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 didn’t 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 30o

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 FINDINGLab value Normal

valueLab Value Normal

value

Leuco

8.920 /µL 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 μ/L 150-390.103 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 : LAD0 Horizontal Axis : normal0 PR interval : 0.12”0 QRS complex : 0.08”0 QT interval : 0.40”0 ST elevation I, AVL0 ST depresion III, AVF0 Conclusion: sinus rhythm with heart rate 72 bpm, STEMI high

laterall wall,

CXR

0AP position, symmetric, strong KV, less inspiration0 Soft tissue thin, Bone normal0Trachea in the middlle0Hemidiaphragm D/S dome shape0Phrenico costalis angle D/S sharp0Pulmo D/S :normal0Cor: site N, size CTR 60%Conclusion : less inspiration looks cardiomegaly

CUE AND CLUE PROBLEM LIST INITIAL DIAGNOSE

PLANINGDIAGNOSE PLANNING THERAPY PLANNING

MONITOR

1. Mr K/52 yoAx: 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 agoFamily history –History hospitalized 2x because of chest painPE : BP BP 150/90mmHgHR 89tpm RR 18tpmECG : Sinus rhytm with ST elevation I, AVL, ST depression II, III, AVFLab :CKMB 19 51Trop I 0.0 1,3

1.STEMI high lateral onset < 1 hour TIMI score 1/14KILLIP I GRACE 98

- Coronary angiography, Echo, Lipid profile

O2 4 lpm NCBed rest Semifowler positionInsert urine condom catheterFluid balance 0/24hIVFD NacL 0.9% 1500 cc/24 hoursInf. Streptokinase no stockInj. LMWH (enoxaparin )2 x 0.6 cc scPo.ASA lx 80 mgCPG 1 x 75 mgAlprazolam 0-0-0.5mgSimvastatin 0- 0- 20 mgISDN 3 x5 mgStool softener 3 x CI

SVSECG

CUE AND CLUE PROBLEM LIST INITIAL DIAGNOSE

PLANINGDIAGNOSE PLANNING THERAPY PLANNING

MONITOR

2. Mr K/52 yoAx : history HTN known since 20 years agoRoutionelly controlled to cardiology outpatient departmentPE : BP 150/90mmHg

2. Hypertension st I (on treatment)

2.1 essential2.2 secondary

As aboveValsartan 1x80mg

SVS

Thank you