Morning Report

Thursday, June 25th 2015

Dr. Nando

Physician in charge :
IB : dr. Hanas, dr. Daya, dr. Kathy
II : dr. Nando (CVCU), dr. Sasmithae (HCU)
II UGD : dr. Zen , dr. Dian
Chief Jaga : dr. Ananto
Konsultan: dr. Atma G, Sp.PD-KGH
Fasilitator MR : dr. Djoko Heri, Sp.PD-KHOM

SUMMARY OF DATA BASE

Female/64 yo/W.CVCU
Chief complaint: shortness of breath (heteroanamnesis)
Patient came to our ER with the chief complained shortness of
breath since 4 days ago and worsen 1 day before admission. The
complained trigerred when she did moderate activity. She sleep on
3-4 pillows, often awaken in the middle of the night. She also said
the complain was accompanied with leg swelling on both of her feet.
This is not the first time she got shortness of breath. The first one
was 1 month ago. At first she got shortness of breath after cleaning
the house, the complained was getting worse and her family brought
her to public health service, she hospitalized there for 5 days. Her
blood pressure at that time was 180/100 mmHg. The doctor said she
got hypertension and also chronic heart failure. After hospitalized,
she reffered to out patient cardiology department, got captopril 3x25
mg, furosemid 1x40 mg, spironolacton 1x25 mg, bisoprolol 1x5 mg,
alopurinol 1x 100mg, simvastatin 1x20 mg.

Family history: her mother had

hypertension
Social history: she is married, with 3
children, she is a house wife.
She got diagnosed hypertension since
5 years ago, not routine took the
medication, especially in the last four
days before admission.

TIMELINE

5 years
ago

1 month ago

3
weeks
ago

2 days
ago

24/6
2015

Physical Examination at Intesive

care

General
appearance

Looked moderatly ill, CM

Blood Pressure

170/100 mmhg

Pulse Rate

100 bpm

Respiratory rate

34 tpm

456

Head

Anemic (- ), ikteric -

Neck

JVP R + 5 cm H2O at 45 degree

Thorax
Heart

Ictus invisible palpable in ICS VI AAL sinistra

RHM = PSL D. LHM = ictus
S1S2 normal

Lung

Symmetric

v
v v

Rh - - Wh
+ +
+ +

Abdomen

Flat, soft, bowel sound (+)

Extremities

Leg swelling +/+, wet and warm acral,

--- -

Hasil Laboratorium 25/06/2015

BGA with NRBM 10 lt/mnt

Parameter
pH

Value

Normal

7.31

7.35-7.45

PCO2

32.5

mmHg

35-45

PO2

263.0

mmHg

80-100

HCO3

16,6

mmol/l

21-28

O2 Saturation

99.1%

> 95

BE

-9,9

Mmol/l

(-3) (+3)

SaO2

99,5%

Conclussion: metabolic acidosis partially compensated

ECG

Sinus tachycardia, Heart rate 102 bpm

Frontal Axis
: normal
Horizontal Axis : clock wise rotation
PR interval
: 0.12
QRS complex : 0.08
QT interval
: 0.32
LV strain at V5-V6
Slow progression of R at V1-V4

Conclusion: Sinus tachycardia, Heart rate 102

bpm, Slow progression of R at V1-V4 and LVH

AP position, asymmetry,
less KV, less inspiration
Soft tissue : Normal
Bone
: Normal
Trachea : In the middle
Heart: : Site : Normal
Size : CTR 80%
Apex difficult to evaluate
Aorta
: Normal
Diafragma : Difficult to evaluate
Sinus costophrenicus : D blunt,
S difficult to evaluate
Lungs
: Chepalization
Conclussion:
Cardiomegaly, pleural effusion dextra,
Pulmonary edema

Conclusion :
Cardiomegaly, pleural
effusion D/S,

Chest X Ray
11

CUE & CLUE

P.
I Dx
LIST

Female/ 64 yo
Ax :
SOB
DOE
PND
Leg swelling
Uncontrolled hypertension

1. SOB

PE:
GCS 456. BP 170/100 mmHg
HR: 100 bpm, regular
RR: 34 tpm
Increase JVP
Heart enlargement
Decrease breath sound basal
bilateral
Rh mediobasal bilateral
Bilateral leg edema
LAB:
ECG:Sinus tachycardia, slow
progression of R, LVH
Lab :
BGA : metabolic acidosis
partially compensated
CXR : heart enlargement, pleural
effusion bilateral
Echo EF 22%, LA,LV,RV
dilatation, global hypokinetic,
Pulmonal HTN End stage HHD
CO = 1,76, SVR 4,181

1 ADHF
1.1 DCM
1.2 HHD
.

P Dx

P Tx

PMo

Total bed rest

Semi fowler postion
O2 10 lpm NRBM
Total fluid 1500 cc/day
IVFD NS 0.9% 500 cc/d
Intake oral fluid 1000 cc/d
Negative fluid balance 1000
cc per day
Liquid diet 6x100cc (1cc ~2
calorie)

Subj,
VS
UOP
Fluid
balanc
ed
Serial
ECG,
serial

Drip furosemid 10 mg/ jam

IV
GTN 5-200 mcg/menit
PO :
Captopril 3x25 mg
spironolacton stopped

CUE & CLUE

P.
I Dx
LIST

Female/ 64 yo
Ax :
Leg swelling
Uncontrolled
hypertension
years

2. HTN
stage 2
5

PE:
GCS 456. BP 170/100 mmHg
HR: 100 bpm, regular
RR: 34 tpm
Increase JVP
Heart enlargement
Decrease breath sound basal
bilateral
Rh mediobasal bilateral
Bilateral leg edema
LAB:
ECG:Sinus tachycardia, slow
progression of R, LVH
Lab :
CXR : heart enlargement, pleural
effusion bilateral
Echo EF 22%, LA,LV,RV
dilatation, global hypokinetic,
Pulmonal HTN End stage HHD
CO = 1,76, SVR 4,181

2. 1 primary
hypertension
2.1
secondary
hypertension
.

P Dx

P Tx

PMo

Anti hypertension waiting

GTN stop and then plan to
give:

Subj,
VS
UOP
Serial
ECG,
serial
Kalium
level

Captopril as above
ISDN 3x5 mg
Valsartan 1x80 mg

CUE & CLUE

P. LIST

I Dx

Female/ 64 yo
Ax :
Uncontrolled
hypertension
5
years, consumed spironolacton

3. Hyperkalemia

3.1 dt drug
induced

LAB:
Kalium: 5.63 5.39

P Dx

P Tx

PMo

Drip furosemid as above

Subj,
VS
UOP
Serial
ECG,
serial
SE
level

Per oral:
Calsium polystiren 2 x 5g

Hypertension

Poor
complianced

Heart failure

Risk Factor Analysis

Age ( 55 yo for men, 65 for women)

Cigarette smoking
Diabetes mellitus (DM)
Dyslipidemia
Family History of premature CVD (men
<55 yo, female <65)
Hypertension (HTN)
Kidney disease (microalbuminuria or
GFR<60 mL/min)
Obesity (BMI 30kg/m2)
Physical inactivity
hsCRP, uric acid, apoB,
hyperhomocysteinemia

Management Analysis

Total bed rest

Semi fowler postion
O2 10 lpm NRBM
Total fluid 1500 cc/day
IVFD NS 0.9% 500 cc/d
Intake oral fluid 1000 cc/d
Negative fluid balance 1000 cc per day
Liquid diet 6x100cc (1cc ~2 calorie)
Drip furosemid 10 mg/ jam IV
GTN 5-200 mcg/menit
PO :
Captopril 3x25 mg spironolacton stopped
Anti hypertension waiting GTN stop and then plan to give:
Captopril as above
ISDN 3x5 mg
Valsartan 1x80 mg
Calsium polystiren 2 x 5g

Condition this morning

Shortness of breath relief

GCS 456
BP 123/63 mmHg
PR 82 bpm
RR 21 tpm
UOP: 2000 cc/ 6 hour

Thank You