DUTY REPORT 2nd December 2015

GP ON DUTY: DR. DEA & DR. ARDIANCOASS ON DUTY: DONDYJULIANSYAH

EMERGENCY UNIT

PATIENT’S IDENTITY

Name : Mrs. LAge : 41 years oldReligion : MoslemMarital Status : MarriedAddress : ASR Rindam Jakarta

Utara

ANAMNESIS

Autoanamnesis on 2nd December 2015 at 9 PM

Chief Complaint : Chest pain at the left for 3 days before admission

Additional Complain: Nausea, Cold sweating

CURRENT ILLNESS

The patient, female, 41 years old, was admitted at emergency room with chest pain for 3 days. Chest pain was at the left and radiated to the left shoulder and back. The characteristic of pain was like being crushed and heavy. It was improved with rest and got worsen with activity. The duration of chest pain was more than 35 minutes. There were nausea but no vommiting. There were also excess of cold sweating. Patient also complained of lacking of sleep for 3 days due to the chest pain. There was no breathlessness. There were no DOE, ortopnea, and PND.

PAST ILLNESS

There was controlled Hypertension There was controlled DM with Metformin 3

times a day

Heart Disease from Mrs. L’s Father Diabetes denied Malignancy denied Stroke denied

FAMILY ILLNESS

HABITS AND LIFESTYLEThere were no history of smoking, alcoholic drinking,

taking drugs

Amlodipine 1 x 5 mg

PAST MEDICAL HISTORY

PHYSICAL EXAMINATION

VITAL SIGNSGeneral State : Moderate SicknessConsciousness : Compos MentisBlood Pressure : 110/80 mmHgPulse : 102 x/minuteRespiratory Rate : 24 x/minuteTemperature : 36,2oCBody Weight : 71 kgBody Height : 160 cmBMI : 27,73 (obese 1)

PHYSICAL EXAMINATION

General Examination Head : Normocephal

Eye : anemic conjunctiva (-/-), icteric sclera (-/-) Ears : normotia, discharge (-) Nose : septum deviation (-), discharge (-) Mouth : oral trush (-), leukoplakia (-)

Neck : lymph nodes enlargement (-) Thorax : symmetric, intercostal retraction (-)

Cor : regular 1st and 2nd heart sound, murmur (-), gallop (-) Pulmo : vesicular breathing sounds, ronki (-/-), wheezing (-/-)

Abdomen : distended (-), bowel sound within,normal limit, timpani, hepar & lien not palpable, absence of pain

Extremities : warm, pitting edema (-), clubbing (-), cyanosis (-) CRT < 2 seconds

DIAGNOSTIC PLANS

RESULT NORMAL RANGE

Hematologi rutin:

Hb 16 13 - 18 g/dl

Ht 46 40 – 52 %

Erythrocyte 5.4 4.3 - 6.0 mil /ul

Leukocyte 10100 4800 – 10800/ul

Thrombocyte 282000 150000 - 400000/ul

MCV 88 80 – 96 fL

MCH 29 27 - 32 pg

MCHC 35 32 – 36 g/dL

LABORATORIUM

RESULT NORMAL RANGE

Kimia klinik:

CPK 89 26 – 140 U/L

CK-MB 12 7 – 25 U/L

Ureum 22 20 - 50 mg/dl

Creatinin 0,8 0.5 – 1.5 mg/dl

Random Blood Glucose 124 < 140 mg/dl

Natrium 139 135 – 147 mmol/L

Kalium 3.7 3.5 – 5.0 mmol/L

Klorida 101 95 – 105 mmol/L

IMUNOSEROLOGI

Troponin I (rapid) -/Negatif -/Negatif

ECG

Sinus tachycardia, HR 125 x/minute, Left Axis Deviation, PR interval 0,12 s, ST Depression on V2, V3

Thorax X-Ray AP

no cardiomegaly, lungs within normal limits

RESUME

The patient, female, 41 years old, was admitted at emergency room with chest pain for 3 days. Chest pain was at the left and radiated to the left shoulder and back. The characteristic of pain was like being crushed and felt heavy. It was improved with rest and got wersen with activity. The duration of chest pain was more than 15 minutes. There were nausea but no vommiting. There were also excess of cold sweating. On physical examination, heart rate is 102x/minute. The laboratory within normal limit. CPK, CK-MB, Troponin I were within normal limit. ECG showed LAD, ST depression on V2 & V3, Thorax X-Ray was within normal limit.

PROBLEMS LIST Unstable Angina Pectoris

ASSESSMENT1. Unstable Angina Pectoris

Anamnesis: The patient, female, 41 years old, was admitted at emergency room with chest pain for 3 days. Chest pain was at the left and radiated to the left shoulder and back. The characteristic of pain was like being crushed and heavy. It was improved with rest and got wersen with activity. The duration of chest pain was more than 35 minutes. There were nausea but no vommiting. There were also excess of cold sweating. There was history of uncontrolled hypertension and medication

DD: NSTEMI ECG: ECG showed ST depression on V2 & V3. But no increase of CPK,

CK-MB

THERAPY

Diagnostic Plan: ECG on serial,Therapeutic Plan

IVFD RL 500 cc 20 tpmAspilet 4 x 80 mgClopidogrel 300 mg ISDN 5 mg sublingualSimvastatin 1x20 mg Bisoprolol 1x2,5 mg

Sumber : ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal (2011)

Sumber : Coronary Heart Disease in Clinical Practice

PROGNOSIS

Qua ad vitam : Dubia Qua ad functionam : Dubia Qua ad sanationam : Dubia ad malam

THANK YOU