Ronde September10

7/25/2019 Ronde September10

1/22

GRAND ROUNDSeptember 10th2015


2/22

NO NAME AGE DIAGNOSIS1 Mr. Sp 57 CHF NYHA III ec CAD 3VD + on PPM +

Ascites + DM

Mr. !" 5# $AP %I&&IP I 'IMI ()7 CAD 3VD + H'st*e II + DM tipe II + post PCI ,sept-15

3 Mr. M #- CHF NYHA III/IV ec se0ere M!'!PH +A 2 NV! + H4pertiroi

( Mr. 'D #- ADHF p** CHF NYHA II ec OMI*nterosept*6 + H' + 4s6ipiei*

5 Mr. PD 7

CC I December 2015


3/22

NO NAME AGE DIAGNOSIS

1 Mrs. S #5 S'EMI in8erior

Mrs. S6 5( CHF ec HHD

3 Mrs. SS 59 CHF ec HHD M! AF

( Mrs. S! #- Pro PAC st*n4 PCI

FEMALE WARD September 3rd 2015


4/22

NO NAME AGE DIAGNOSIS

-1 1 Mr. % (# CHF NYHA II ec A! se0ere

Possi6e IE

Mr. N # S'EMI in8eroposterior

- 1 Mr. S # CHF NYHA III ec s:sp IHD DMe8:si p6e:r* :p6e;

CHF ec IHD pro PCI

-3 1 Mr. S" 5# APS CCS II/III pro PCI

#5 CHF recent S'EMI *nterior

-( 1 Mrs. S < CHF NYHA III ec HHD AFs:c6inic*6 H4pertiroi

Mrs. N 5# CHF ec DCM 4s6ipiei*

-5 1 Mr. Sn #5 NS'EMI =i66ip I

Mr. > (( S'EMI e;tensi0e *nterior?istor4 o8 A&O post PCI

CC I J!e 1"th 2015


5/22

Diagnosis

NSTEMI

CHF NYHA II ec IHD

PCI history in March 2015 Hypertension st II

Dysipi!e"ia


6/22

C#$e %&$tr#t%'!

Patient identity

Na"e # Mr S

A$e # %% yo

A!ress # &esani 'T ()'* 1

+cc,pation # 'etire!

Date o- a!"ission # Septe".er /th 2015

Ins,rance # &PS non P&I


7/22

Recent history

Chief complaint : chest pain

At 'SD

Chest pain 34 Patient too6

another ISDN s,.in$,ay Pain

!ecrease! a itte in intensity

Dyspnea 748 Papitation 748

syncope 74

9 ho,rs .e-ore a!"ission

Chest pain 348 -et i6e hea:y press,re8 ra!iatin$ to nec6 an

e-t ar"8 90 "in,tes !,ration8 !i! not reie:e ;ith rest Na,sea

348 Diaphoresis 348


8/22

!IS% FAC'O!S FO! CAD

()perte!$%'!

*+,

DM *-,

D)$&%p%dem%#

*+,

Sm'.er *-,

F#m%&)

h%$t'r)

*-,PAS' MEDICA& HIS'O!Y

G*stritis /

Ast?* /

A66er4 /

Stro=e /

%ine4 ise*se /

A6co?o6 *:se /


9/22

Meic*tion ?istor4

Mini*spi 9-)(?o:r

F:roseie (-)(?o:r

Di6ti*e 3-)1?o:r C6opis*n 75)(?o:r

Si0*st*tin 1-)(?o:r

Ison*t 1-)(?o:r Spirono6*ctone 5)(?o:r

Dio0*n 9-)(?o:r


10/22

F*i64 Histor4

H4pertension ,+

'?ere is no 8*i64 eer "it??istor4 o8 ?e*rt ise*se


11/22

PHYSICA> E?AMINATI+N

Ge!er#& C'!d%t%'! #!d /%t#&

S%!$&e0e6 o8conscio:sness

Coposentis

GCS E(V5M#

Gener*6conition Moer*te64 i66

Bei?t #- =

Hei?t 1#5 c

@MI -3 =)

@P 1#-)1-- HH!


12/22

PHYSICA> E?AMINATI+NChe$t

HEA!'Inspection IC c*n e seen on 5t? ICS

c 6*ter*6 to &MCSP*6p*tion IC "*s p*6p*te on 5t?ICS

c 6*ter*6 to &MCS

A:sc:6t*tion Nor*6 S1 S M:r:r ,/ G*66op ,/

&$NGInspection S4etric "?i6e in st*tic

4n*ic st*teP*6p*tion E:*6 ste 8reit:s in ot?

6:n 2e6sPerc:ssion SonorA:sc:6t*tion Vesic:6*r +)+ !*6es +)+ ini*6 *t 6:ns

*se Cr*c=6es /)/ B?eein /)/


13/22

Abd'me!

Inspection F6*tA:sc:6t*tion Nor*6Perc:ssion D:66 in ri?t :pper :*r*nt s?i8tin :66nes ,/P*6p*tion &i0er c*n e p*6p*te c e6o" *rc:s cost*e

Etrem%t%e$

B*r e;treities Ee* /)/ C4*notic /)/ G*strocnee:s p*in /)/ C6:in 2ner /)/

PHYSICA> E?AMINATI+N


14/22

DIAGNOS'IC S'$DIES


15/22

-


16/22

ECG ,Septeer 9t?-15 -7.--

Sin:s r?4t?. #-;)enit. &AD. &AF@. &AE. p*to6ois i V1/V5


17/22

&*or*tori:

PEME!I%SAAN HASI& SA'$AN NI&AI NO!MA&

HEMA'O&OGI ,7)< -15

H 133 )& 1-- J 15--

Hct 37 K 35 J (7

Eri (11 1-#)L& (( J 5

Ronde September10

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