MORNING REPORT

Sunday, August 5th, 2012

PHYSICIAN INCHARGE: IA : dr. Eva, dr. Betty, dr. Yuli IB : dr. Rusyda, dr. Fajarsari II : dr. Nani Z. III : dr. C. Singgih Wahono, SpPD MODERATOR: dr. Budi Darmawan, SpPD-KHOM

Summary of Data Base

Mr. S/Male/55 y.o/W 24 B Chief Complaint : chest pain

The patient suffered from chest pain since 5 hours before

admission, at the left area, heavy sensation, radiated to the back, did not radiated to the jaw/left arm, lasted for 30

minutes, while patient was sleeping (at 4 oclock in the

morning). The complaint was accompanied by shortness of breath. Actually, the patient has been suffering from shortness

of breath since one year ago, but it has got worsened since
the last two weeks. The shortness of breath occurred during activities (walking more than 5 meters), and subsided during

rest.

 The patient slept using 3 pillows, he often woke up suddenly at night due to shortness of breath. He had history of both leg swelling since months ago, and it subsided by drugs prescribed by a mantri (the effect of the medicines was increase of urination). The patient complained about his urination, which he experienced hesitation and dribbling at the end of his urination. The patient also complained about abdominal pain, especially at epigastric area, with burning and stabbing sensation History of HT (+) 180/ mmHg, known since 6 months ago, but the patient did not routinely consumed any particular medicines

Physical Examination
BP: 116/93 (ER) 120/80 mmHg HR: 112 bpm (ER) HR: 93 bpm (Ward); PR: 93 bpm (irregular-irregular) RR: 20tpm T.ax: 37 0C

General Appearance : looked moderately ill Head Anemic conjunctiva(-)

GCS : 456 BW: 46 Kg; BH 165 cm; BMI: 16.89 Kg/m2 Icteric sclerae (-) LN enlargement (-)

Neck Chest

JVP : R + 2cm H2O; 300 Heart Ictus visible and palpable at 6th ICS, 7 cm lateral from MCL S (3cm of wide) RHM 2 cm SL Dextra;LHM ictus S1, S2 single, no murmur
Lung Symmetric; SF D=S; S| S S| S S| S V|V V|V V|V no additional breath sound

Abdomen Extremities

Flat, BS (N), Liver span68 cm, traubes space tympanic, soft, tenderness (+) at epigastric area Warm; Edema (-)

Laboratory Findings
Lab Leukocyte Hemoglobine PCV Result 9.050 11.5 34.3 Normal Value
3,500-10,000/L 11.0-16.5 g/dl 35-50%

Lab Sodium Potassium Chloride

Result 136 3.50 99

Normal Value
136-145 mmol / L 3.5-5.0 mmol / L 98-106 mmol / L

Thrombocyte
SGOT SGPT

264,000
43 30

150,000390,000/l
11-41U/L 10-41U/L

RBS
Ureum Creatinine Albumin

135
35 1.04 4.02

> 200 mg/ dL

10-50 mg/dL 0.7-1.5 mg/dL 3.5-5.5 g/dL

05/08/2012 CK CKMB Trop I

160 44 0.50

39-308 U/L 7-25 U/L (+)>1.0 U/L

Urinalysis
Lab SG PH Leucocyte Nitrite Protein Glucose Erythrocyte Keton urine Urobilinogen Bilirubin Value 10 x Lab Value

Epithelia
Cylinder Hyaline Granular Leukocyte Erythrocyte 40 x Erythrocyte Leukocyte Crystal Bacteria

Blood Gas Analysis

Result Normal Value
pH 7.50 7.35 7.45 PCO2 41.7 35 45 PO2 147.7 80 100 HCO3 31.8 22 26 SaO2 99.1 90 100 BE 8.7 -3 -+3 Conclusion: metabolic alkalosis uncompensated + hyperoxemia

ECG Interpretation
HR 100 bpm PR Interval: hard to be evaluated QRS Complex: 0.06 QT Interval: 0.32 Frontal Axis: normal Horizontal Axis: CWR T inverted at V5-V6 QS pattern at V1+V2 Conclusion: AF 100bpm, ischemic at lateral wall, OMI anterior wall

X-RAY INTERPRETATION
AP position, symmetric, enough KV, enough inspiration Trachea: deviated t the right Soft tissue: thin, and bone: normal Hemidiaphragma D:dome shape; coverewd by cardiac imaging Sinus phrenicocostalis D: sharp; S: cut by film Pulmo : thickening of hillus D, BVP normal Cor : CTR 70% Conclusion: cardiomegaly

CUE & CLUE

PL

IDx

PDx

PTx

PMo

Male/55 YO -left chest pain, radiated to the back, for 30 minutes -SOB;DOE;PND -History of smoking (+) -History of HT (+) -BP 120/80 mmHG -HR112 93x/m irreguler-irreguler -RR 4018 tpm -ECG: AF HR 110 bpm, OMI anterior, ischemia lateral wall -CPK 160 U/L -CKMB 4 U/L -Trop I 0.5 U/L

1. Atypical Chest Pain

1.1 AF 1.2 GERD

-O2 8-10 LPM NRBM -Bed rest -Semifowler postiion -Heart diet 1,700 Kcal.Day, low sodium <2 gr/day -ISDN 3x10mg (PO) (EM)

-Subj -VS -UOP Cardiac enxym -ECG -

CUE & CLUE Male/55 YO -left chest pain, radiated to the back, for 30 minutes -SOB;DOE;PND -History of smoking (+) -History of HT (+) -BP 120/80 mmHG -HR112 93x/m irregulerirreguler -RR 4018 tpm -ECG: AF HR 110 bpm, OMI anterior, ischemia lateral wall

PL 2.Af RVR NVR

IDx 2.1 dt. No.1

PDx

PTx -O2 8-10 LPM NRBM -Bed rest -Semifowler postiion -Heart diet 1,700 Kcal.Day, low sodium <2 gr/day -EM: Inj. amiodarone 150mg (IV) bolus drip amiodarone 150mg in 100cc NaCl 0.9% -Internal medicine ER: Inj. Digoxin 0.5mg (IV) bolus at 12.30 4 hours later (still RVR): Inj. Digoxin 0.5mg (IV) bolus at 16.30(NVR) -Ward: Digoin 1x0.25 mg (PO) -ASA 1x80mg

Pmo -S -VS -ECG

CUE & CLUE

PL

IDx

PDx

PTx

PMo

Male/55 YO -SOB,DOE,PND -History of leg swelling -History of HT (180/mmHg) -History of smoking -BP 120/80 mmHG -HR112 93x/m irregulerirreguler -RR 4018 tpm -ictus: 3cm wide, at ICS 6, 7cm lat from MCL Sx, RHM 2 cm lat from SL D -CXR: cardiomegaly
Male/55 YO -Abdominal pain, at epigastric area -Burning sensation -Chest pain -Tenderness at epigastric area

3.HF Stg. C FC III

3.1 CAD 3.2 HHD

-Lipid profile -Echocardiography

-Bed rest, -S semifowler -VS position -UOP -Heart diet 1,700 Kcal.Day, low sodium <2 gr/day -ISDN 3x10mg -Captopril 3x12.5 mg (postponed) -Simvastatin 1x20mg

4.GERD

-Endoscopy

-Inj. Ranitidin 2x50mg (IV)

-S -VS

Condition This Morning

S: GCS: 456 BP: mmHg HR: bpm PR: bpm RR: tpm UOP: cc/H

THANK YOU