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MORNING REPORTSunday, 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, SpPDMODERATOR: dr. Budi Darmawan, SpPD-KHOM
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Summary of Data BaseMr. 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 shortnessof 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.
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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 itsubsided 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 ofhis urination.
The patient also complained about abdominal pain,
especially at epigastric area, with burning andstabbing sensation
History of HT (+) 180/ mmHg, known since 6
months ago, but the patient did not routinely
consumed any particular medicines
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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 GCS : 456
BW: 46 Kg; BH 165 cm; BMI: 16.89 Kg/m2
Head Anemic conjunctiva(-) Icteric sclerae (-) LN enlargement (-)
Neck JVP : R + 2cm H2O; 300
Chest 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 V | V no additional breath sound
S| S V | VS| S V | V
Abdomen Flat, BS (N), Liver span68 cm, traubes space tympanic, soft,
tenderness (+) at epigastric area
Extremities Warm; Edema (-)
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Laboratory FindingsLab Result Normal Value Lab Result Normal Value
Leukocyte 9.050 3,500-10,000/L Sodium 136 136-145 mmol / L
Hemoglobine 11.5 11.0-16.5 g/dl Potassium 3.50 3.5-5.0 mmol / L
PCV 34.3 35-50% Chloride 99 98-106 mmol / L
Thrombocyte 264,000 150,000-
390,000/l
RBS 135 > 200 mg/ dL
SGOT 43 11-41U/L Ureum 35 10-50 mg/dL
SGPT 30 10-41U/L Creatinine 1.04 0.7-1.5 mg/dL
Albumin 4.02 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
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Urinalysis
Lab Value Lab ValueSG 10 x
PH Epithelia
Leucocyte Cylinder
Nitrite Hyaline
Protein Granular
Glucose Leukocyte
Erythrocyte Erythrocyte
Keton urine 40 xUrobilinogen Erythrocyte
Bilirubin Leukocyte
Crystal
Bacteria
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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
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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
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X-RAY INTERPRETATION
AP position, symmetric, enough KV, enoughinspiration
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
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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 1,700Kcal.Day, low sodium
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CUE & CLUE PL IDx PDx PTx Pmo
Male/55 YO
-left chest pain,
radiated to the
back, for 30minutes
-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
2.Af RVR
NVR
2.1
dt.
No.1
-O2 8-10 LPM NRBM
-Bed rest
-Semifowler postiion
-Heart diet 1,700 Kcal.Day, lowsodium
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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 irreguler-
irreguler
-RR 4018 tpm
-ictus: 3cm wide, at ICS 6,
7cm lat from MCL Sx, RHM
2 cm lat from SL D
-CXR: cardiomegaly
3.HF
Stg. C
FC III
3.1 CAD
3.2 HHD
-Lipid profile
-Echo-
cardiography
-Bed rest,
semifowler
position
-Heart diet 1,700Kcal.Day, low
sodium
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Condition This Morning
S:
GCS: 456
BP: mmHg
HR: bpm
PR: bpm
RR: tpm UOP: cc/H
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THANK YOU