Sunday, May 16th 2011

MORNING REPORT
PHYSICIAN INCHARGE: IA : dr. Sigit, dr. Asri, dr.Yana IB : dr. Angga dr. Retno II : dr. Aris dwi III : dr. Didi C, SpPD

Summary of Data Base

Mr. Munib Efendi/45 y.o
Chief complaint: chest pain Patient had suffered from chest pain in the midle of chest since 1 week ago, but relieve and present again. The pain relieve with rest, when chest pain,It was accompanied with nausea and cold sweating. He suffered from last chest pain 1 days before admission and patient was took (asa 1x80 mg, Clopidrogel 1x75 mg, and ISDN 1x10 mg) by doctor in pasuruan.
He had history of hypertension since 10 years ago,not routinly control. The blood pressure usually 140-150/-. Not routinely took medication because he think his blood pressure was normal He is heavy smoker (1-2 pack/day)

Physical Examination
General appearance: looked moderately ill, GCS: 456 BP: 140/90mmHg ; HR: 70 bpm, reguler; : 20 x/mnt; T : 36.5 Head & Neck: an (-), ict (-), JVP R+2cmH20 Thorax : Heart : ictus invisible, palpable at 2 cm lat ICS V MCL S LHM ~ ictus, RHM at 2 cm lat SL D S1, S2 single, murmur (-) Lung : Simetris, S S V V Rh - - Wh - S S V V - - S S V V - - Abdomen: flat, soefl, BS (+) N, met (-) Liver: unpalpable, liver span 10 cm Spleen: unpalpable, troube space tympani Extremity: edema -

LABORATORY FINDING
Lab
Leukocyte Haemoglobin

Value
7600 12,3 3500-10000/L 11,0-16,5g/dl

Lab
SGOT SGPT

Value 11-41 U/L

10-41 U/L 3.5-5.5 g/dl

Trombocyte
Hematocrite RBS Ureum Creatinine CPK CKMB Troponin I

273.000
37,3 102 24,7 0,77

150000-390000/L Albumin

(<200)mg/dL 10-50g/dL 0,7-1,5mg/dL 10-80 U/L 2-10 U/L: - ng/ml Na K Cl 137 4,07 107 136-145 mmol/L 3.5-5.0 mmol/L 98-106 mmol/L

350 29
-

ECG
Sinus rhythm, HR 75 x/mnt Frontal axis: Normal axis Horisontal axis: Normal axis PR interval: 0,12 QRS comp: 0,08 QT interval: 0,36 T inverted at,II,III,aVF,V1-V6 Conclusion; sinus rhythm Hr 75x/mnt with ischemic inferior and antero lateral.

Chest X-Ray
Thorax AP, less KV , asimetris, less inspiration, soft tissue normal, bone N, hemidiaphragma D/S dome shape costophrenico angel D/S sharp, BVP normal, Cor CTR 70 % Conclusion :cardiomegaly

CUE AND CLUE

PROBLEM LIST
1. Typical chest pain

INITIAL DIAGNOS E 1.1 UAP 1.2 NSTEMI

PLANNING DIAGNOSE

PLANNING THERAPY
O2 NC 4 lpm Bedrest IVFD NS 0.9% lifeline Fasting 8 hours than Heart diet I 1500 Kcal/day LMWH 2x0.6 cc sc ASA 320mg than 1x160mg CPG 300 mg than 1x75 mg ISDN 3x5 mg Diazepam 3x5mg Simvastatin 0-20mg Stool softener 3xC1

P mon
VS, cardiac enzym ECG

Male, 45 y.o Left chest pain onset >24 hours Heavy smoker hypertension CPK 350 CKMB 29 Troponin I (-) ECG: T inverted in II,III,aVF,V1-V6.

Coronary Angiography

Male, 45 yo BP: 140/90 mmHg Hypertension since 10 years ago not routinely controled

2. Hypertension St I

funduscopy
2.1essensi al HT 2.2 renoparen cimal HT

Captorpril 3x 6,25 mg ISDN as above

BP

Present condition
Symtoms : chest pain relieve BP : 130/80 mmhg HR : 75x/mnt RR : 18x/mnt