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MR 16:12:21 tanpa echo

Morning report Cardiology

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MR 16:12:21 tanpa echo

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  1. Morning ReportWednesday, December 16th2021 Andrea Maya Mezly Jerico Rifna Fitri Irma Rina Ilzy

  2. 1stPatient Identity Name : Mr. AF Age : 55 years old Date of birth : 08-02-1965 Address :Makassar MR :892998 Date of Admission: December 16th, 2021 DPJP : dr. AHA Patient was referred from Grestelina Hospital with CHF+ anterolateral MI onset>24hours DM type II

  3. History Taking Chief complaint : Chest pain Chest pain felt since 48 hours before admitted to the hospital with duration > 20 minutes, pressed-like sensation, radiated to back, accompanied with diaphoresis. There was no shortness of breath, Nausea, and Vomiting. NRS was 5/10. Chest pain was reduced spontaneously. When arrived at hospital, There is no chest pain. History of DoE (+), PND (-), Orthopnea (-). There was history of cardiovascular disease. The patient came to cardiologist in June 2021 because of Shortness of breath. Patient was treated with clopidogrel 75mg, farsorbid 10mg, furosemide 40mg, atorvastatin 20mg, amlodipine 5mg, glimepiride 4mg. History of hypertension (+) since 1 years ago didn’t take medication regularly History of Diabetes mellitus (+) since 5 years ago, took glibenclamide 5mg routinely There was history of smoking since 30 years ago, about 38 pcs/day

  4. Physical Examination BP: 138/68 mmHg, Pulse : 81 bpm regular, RR : 20 tpm, T: 36.50C SpO2 : 99 % room air Conjunctiva not anemic, sclera not icteric JVP R+2 cmH2O Vesicular breath sound, no rales and wheezing S1/S2 regular, no audible murmur Hepar/lien not palpable Peristaltic (+) normal Extremity:warm palpable, oedema (-)

  5. ECG at Grestelina Hospital (16/12/2021) • Sinus rhythm, HR 75 bpm, regular, normoaxis, P wave 0.08 sec, PR interval 0.16sec, QRS duration 0.12 sec, pathological Q wave II,III, aVF, V4-V6. S V1+ R V6>35mm, T inverted I aVL, V5-V6. • Sinus rhythm, regular, LVH, OMI inferior et anterolateral, ischaemic lateral wall

  6. ECG at E.R PJT (16/12/2021) • Sinus rhythm, HR 93 bpm, regular, normoaxis, P wave 0.08 sec, PR interval 0.18sec, QRS duration 0.12 sec, Pathological Q wave II,III, aVF, V4-V6. S V1+ R V6 > 35mm, T inverted I aVL, V5-V6. poor R wave progression • Sinus rhythm, regular, LVH, OMI inferior et anterolateral, ischaemic lateral wall

  7. Lab. FindingsDecember 16th 2021 NLR 2.97

  8. Echocardiography bedside (16/12/21)

  9. ASSESSMENT Non ST Elevation Myocardial Infarction High Risk Hypertensive Heart Disease Severe Hypokalemia (2,5) Diabetes Mellitus type 2 Non Obese

  10. Management IVFD Nacl 0.9% 500 cc/24 hours/intravenous Loading Aspilet 160 mg/oral, maintenance 80 mg/24 hours/oral Clopidogrel 75 mg/24 hours/oral Atorvastatin 40 mg/24 hours/oral Farsorbid 0.5 mg/hours/syiringe pump Furosemide 40 mg/24 hours/oral Candesartan 8 mg/24 hours/ oral Spironolactone 25 mg/24 hours/oral Arixtra 2.5 mg/24 jam/Subcutaneous (1) Drip KCL in Nacl 0.9% 500cc/ 24hours/intravenous

  11. Planning Monitoring vital sign and haemodynamic Nasopharyngeal PCR swab Move to CVCU if swab negative Echocardiography full study if swab negative Consult to EMD division

  12. Thank You

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