MORNING REPORT

Monday, February 20th 2017

COASS INCHARGE:
Rani Astari
Selwina Khony
Kevin Leonardo

CONSULENT : dr. Iqbal Lahmadi

Sp.PD
 Total patients :
ER (AU : BPJS : U: )
Ward (AU : BPJS : U: )
Death case : 1 patient
Interna :
Melati ward patients
Kenanga ward 13 patients
Total patients from 15 pm 04 am :
3 New-in patients
Male/49 yo/EH
Male/ yo /CKD + DM type 2
Female/25 yo/DF
Summary of Data Base
Male/40 y.o
Chief complaint: left chest pain
Patient suffered left chest pain radiated to
the left back and left arm in the last 5 hours
before admission. The pain was accompanied
with nausea, vomit (5x), cold sweating and
heartburn.
He had never diagnosed as diabetes and
cardiovascular disease before.
He had history of hypertension since 2014
 Physical Examination
BP = 140/100 HR = 80x, reguler RR = 21 T ax 36,7 C
mmHg SpO2 : 97%
General appearance : looked severe ill GCS : E3 V5 M6
Head anemic (-/-) icteric (-/-)
Neck wnl

Thorax
Cor wnl

Pulmo Simetric, SF D = S SS v v Rh - - Wh
--
SS v v - -
- -
DS v v - +
- -

Abdomen Flat, Soefl, Hepatomegaly (-), bowel sounds (+), skin

turgor normal (+), epigastric pain (+)
Extremities Oedema -/-, CRT 2s
 LABORATORY FINDING
Lab, 20 Feb 2017 Value Lab Value

Leukocyte 18.100 3500-10000/L SGOT 21 11-40 U/L

Eritrocyte 5,90 3,50-5,50

Haemoglobin 17,4 11,0-16,5g/dl SGPT 25 10-41 U/L

MCV 90,5 75-100 fl Albumin 3.5-5.5 g/dl
MCH 29,6 25-35 pq
Trombocyte 150000-390000/L
254.000
Hematocrite 53,4 35-55
RBS 81 (<200)mg/dL

Ureum 10-50g/dL Na 136-145

mmol/L
Creatinine 0,7-1,5mg/dL K
CPK 10-80 U/L 3.5-5.0
Cl mmol/L
CKMB 2-10 U/L:
98-106
Troponin I - ng/ml mmol/L
ECG
Synus rhythm, HR 100x/mnt
Frontal axis: Normal
Horisontal axis: Clockwise
PR interval: 0,12
QRS comp: 0,06
QT interval: 0,32
T inverted at II, III, aVF
Conclusion; sinus rhythm HR 100 with T inverted
with IMA inferior
CUE AND PROBLEM INITIAL PLANNING PLANNING THERAPY P mon
CLUE LIST DIAGNOS DIAGNOSE
E
Male, 40y.o 1. IMA Coronary Total bedrest, semi VS,
fowler position
Left chest pain inferor Angiogra cardiac
phy Fasting enzym
onset 5 hours Chest
Foley catether
BP 140/100 ECG
Pain O2 NC 4 lpm
Killip IVFD NS 20dpm
Nausea and class Ranitidin 2x50mg (iv)
vomitting IV Morfin2-4 mg iv
Vagal
Relux Nitrat SL
ECG: T-inverted
Arixtra 1x1 vial
(II,III,AVF)
(2,5 mg) sc 3
days
Clopidogrel
4x75 mg tab
Aspilet 4x80mg p.o, 1x
8omg p.o
Bisoprolol 1x 2,5mg
Valsartan 1x 80 mg
Simvastatin 1x20mg
Diazepam 2x5mg
Laxadin 3x15cc
 KILLIP
Clas Definition Mortality
s (%)
I No congestion heart 6
II failure sign 17
III + S3 and / or basiler rales 30-40
IV Pulmonary edema 60-80
Cardiogenic shock
On the left an overview of
the coronary arteries in
the anterior projection.

Left Main or left coronary

artery (LCA)
Left anterior descending
(LAD)
diagonal branches (D1,
D2)
Septal branches
Circumflex (Cx)
Marginal branches
(M1,M2)

Right coronary artery

Acute marginal branch (AM)
AV node branch
Posterior descending artery
(PDA)
 On the left an overview
of the coronary arteries
in the right anterior
oblique projection.

Left Main or left coronary

artery (LCA)
Left anterior descending
(LAD)
diagonal branches (D1, D2)
septal branches
Circumflex (Cx)
Marginal branches (M1,M2)
Right coronary artery
Acute marginal branch
(AM)
AV node branch
Posterior descending artery
(PDA)