MORNING REPORT

Thursday, September 26th, 2019

Presenter:
Amira Fithri Rofifa
201910401011065

Consultant:
dr. Vitriyaturrida, SpJP
  Name : Mrs. Jumina
 Sex : Female
 Age : 46 years old
Identity
 Address : Dsn. Ban Lanjak, Ds/Kel. Tlonto Raja, Kec.
Pasean, Kab. Pamekasan
 Hospitalized : Tuesday, September 25th 2019
  Mrs. J / 46 y.o / 424022
 Main complaint: palpitation
 Patient felt her chest is pounding rapidly after she came home
from farming at 3 p.m. She admitted that she also had chest
pain that radiating to neck and jaw on 2 days ago. The duration
of chest pain is more than 30 minutes. She also felt burning
SUBJECTIVE sensation on chest when the chest pain occurred. She found
that her chest pain relieved when she was resting. She also
complained that she usually felt tightness on breath, mostly
when the night comes. She usually slept with 2 pillows or more.
She also complained that she often being awaken while
sleeping, so she only slept for about 3 hours at night.
Sometimes she felt shortness of breath while walking after
bathing.
  History of the disease:
 DM (-)
 Chest pain (+) :1x typical chest pain 1 year ago, hospitalized in
Summary of Mawar Room, RSUD SMART
 History of the social-relation:
Database
 Patient used to drink coffee, but has stopped for the last 2 years
 History of the therapy:
 She doesn’t memorized the drug she has taken
  Vital Sign: BP: 190/93, HR:181 x/minute, Temp: 36,3, RR: 24
x/minute,SpO2: 98 % on nasal cannule 4 lpm
Head/Neck
Conjuctiva pale -/-, icteric sclera -/-
Thorax
Cor: Ictus cordis invisible, palpable. Single S1-S2 , murmur (+), gallop
(-)
Pulmo: symmetrical, rh -/-,wh -/-
OBJECTIVE +/+
+/+
Abdomen :
Soefl, tenderness(-), Bowel sound (+) Normal

Extremities
Edema -/-, warm acral +/+
 CXR
September, 26th 2019
 AP position, symmetrical
 Bone: Costa R/L normal
 ICS R/L normal
 Trachea: In the middle
 Hillus R/L: N
 Cor: Site: N
 Size: CTR 73 %
 Cardiac waist (+)
 Hemidiaphragm:
 R: dome-shaped
 L: dome - shaped
 Costophrenic angles: right – left
sharp
 Pulmo: Normal

 Conclusion : Cardiomegaly
 Laboratory Finding
Date: September, 25th Parameter Result Normal Value
2019
Hb 15.8 g/dL 13.4 – 17.7 g/dL

Leukocytes 11.450 /µL 4300-10300/µL

Eritrosit 5.57 juta 4.5 – 6.2 juta/cmm

Hematocrit 45,6 % 40 – 47 %

Thrombocytes 225.000 /µL 142000-424000/µL

Random Blood 193 g/dL <200 mg /dl

Sugar
 ASSESSMENT TREATMENT
1. Supraventricular tachycardia Planning Diagnosis :
Serial ECG

Planning Therapy :
Bedrest
O2 Mask 15 lpm
Infus PZ 0.9 % 500 cc/24 hour
Inj. Herbesser 0,25 mg/kg for 2 minutes

Asking for advice from Cardiologist

 ASSESSMENT TREATMENT
1. Acute on chronic Heart failure Planning Diagnosis :
stadium C Functional class III Serial ECG, Echocardiography, cardiac marker
Precipitat factor ACS
Planning Therapy :
Bedrest
O2 Mask 15 lpm
Infus PZ 0.9 % 500 cc/24 hour
ACEI
Inj. Furosemid 3x 40 mg I.V

Asking for advice from Cardiologist

 ASSESSMENT TREATMENT
1. NSTEMI dd UAP Planning Diagnosis :
Serial ECG, Echocardiography, cardiac marker

Planning Therapy :
Bedrest
O2 Mask 15 lpm
Infus PZ 0.9 % 500 cc/24 hour
CPG 300 mg
Aspilet 320 mg
Atorvastatin 1 x 40 mg po
Anticoagulant: LMWH (Lovenox)/UFH
(Heparin)/Fondaparinux

Asking for advice from Cardiologist