ER Report

Wednesday, 01/03/2017

ER Physician on duty :
Dr. Nita and Dr. Ike

Abby W
Widya Kesuma
Patient Recapitulation
1. Mr. A /56 years old/ Hipoglikemia on DM
2. Mr. AA/ 67 years old/ ACS
3. Mm. I/38 years old/ Fever H+1
Identity
Name : Mr, AA
Age : 67 YO
Education : High School
Marriage status : Married
Religion : Islam
Occupation : Private Worker
Residental Address : Kedoya , Kebon Jeruk
Anamesis
Chief complaint :
Chest pain since 3 hour BHA
Anamnesis
Present illness :
Chest pain on the left side since 3 hour BHA, Patien
described about the pain that spread to neck and
backside, and felt like being squeezed very hard. The
Pain does not resolved when the patient took a rest
from his prior activities.
The pain also acompanied with cold sweating,
difficutly in breathing and flutter. Each episode of pain
durates for about 60 minutes. The Patient also
complained that he easily felt tired from doing light
activites, such as walking to the bathroom, going
upstairs
There is no nausea and vomiting. The Patient had a
history of uncontroled Hypertension for at least 8
years and Heart conditions for 5 years
 Past illness Medication history

ISDN 5mg
Same illness as Bisoprolol 5mg
before (-)
Digoxin 0,25mg
Hypertension and
Clopridogel 75mg
Diabetes denied
Candersartan 16mg
Anamnesis
Family illness history Social history
Hypertension (-)
Have history
DM (-)
Allergic (-) of Smoking, at
Heart Conditions (-) least 16
Liver diseases (-) cigarette a
Tumor (-) day, for 20
years, stopped
smoking at
2000
Alkohol
consumption
(-)
Physical examination
General condition : Moderate
Consciousness : Compos mentis
Vital signs
BP : 177/91 mmHg
HR : 66x /minute, reguler
T : 36,8 0C
RR : 20x / minute

Body Weight : 50 Kg
Body Height: 160 cm
BMI: 21,48 (normoweight)
Physical examination
Head : Normocephal
Hair : black , even distribution , strongly
attached
Eye : anemic conjungtiva -/- , icteric sckleric
-/- , light reflects+/+ isocor.
Nose : secretions -/- , septum deviation
Ears : secretions-/- ,
Mouth : moist mucose , cyanosis - , hyperemic
tounge (-)
Neck : enlargement lymph gland (-)
 Physical examination
Thorax (Pulmo)
Inspection : lesion (-), simetric movement
when statics, and dynamics, intercostae
retraction (-)
Palpation : simetric movement , Vocal
fremitus left+right
Percution : Sonor in all lung fields
Auscultation : Vesikuler breath sounds
(+), Rhonki (-), wheezing (-)
Physical examination
Thorax (cor)
Inspection : Ictus cordis cannot be seen
Palpation : Iktus cordis palpable
Percussion: heart left line : left deviation about 2
cm from ICS V Linea Parasternal Sin
heart right line : ICS III Linea
Parasternal Dextra
heart waist line : ICS IV Linea
Midclavicularis Sin
Auscultation: HS I-II reguler, gallop (-),murmur (-)
 Physical examination
Abdomen:
Inspection: swelling (-) Scar (-), caput medusa (-),
Auscultation: Norma Bowel sound (+) 8x/mnt
Palpation : Tenderness(-) on abdominal field
Liver and spleen are not palpable
Percussion : Tympani on abdominal field

Ekstremities : All warm, edema (-), pale (-), CRT

< 2sec
 Laboratory findings

Examination Result Normal value

Hb 13.1 13 18 g/dL
Ht 38 40 52 %
Eritrosit 4,2 4,3 6,0 juta/uL
WBC 7910 4800 10800 / uL
Platelet Count 319.000 150000 400000 / uL
MCV 81 80-95 fl
MCH 29 27-32 pg
MCHC 35 32-36 g/dl
Examination Result Normal value
CPK 68 38-174 U/L
CKMB 15 7-25 U/L
Urea 22 20-50 mg/dl
Creatinie 1,0 0,5-1,5 mg/dl
Blood Glucose 140 <140mg/dl
Troponin <0.01 <0,02 ng/ml
ECG
Resume
Pasient, male , 67 YO, came with chest pain since 3
hours BHA. Pain spread to the neck and shoulders. Pain
accompanied with cold sweats, flutter and easily get
tired from doing light activities. Patient had a history of
uncontrolled hypertension and heart diseases for at least
10 and 5 years, respectively

Physical examination findings : ,Vital sign, 177/91mmhg.

Increased left Heart line , 2cm deviation to sinistra

Laboratory findings
CPK, CKMB, Troponin cardiac markers are in normal
values
 Assessment
1. Chest Pain ec UAP
Ax : chest pain that migrates to shoulder and neck, pain does
not resolve when resting, with onset of 60 minutes,
accompanied by cold sweats.
PE : left heart line deviates 2cm to the axilla from midclavicula
sinistra
LF : CPK (68 u/L), CKMB (15u/L), Troponin (<o,o1) all within
normal ranges
ECG : Normal Sinus rythym, HR : 70x/mnt, Normal axis, no
abnormalities
Planning :
Diagnose : Angiograph
Therapy :
O2 2lpm NK
IVFD Nacl 500 ml / 8 jam
ISDN tab 1 x tablet sublingual
 Assessment
2. Grade 2 Hypertension
Ax : History of uncontrolled Hypertension
for 8 years
PF : Vital sign, BP : 177/91 mmhg
LE : (-)
Planning :
Diagnosis : (-)
Therapy : Catopril 12,5mg combination
with hidroklorotiazid 50mg/daily
PROGNOSIS
Quo ad Vitam : Dubia ad bonam
Quo ad Functionam : Dubia
Quo ad Sanationam : Dubia