JUDUL KASUS

I. CASE
A. Patients Identity
Name
Sex
Age
Height
Weight
Marital status
Occupation
Pregnancy status*
Address
Examination date
B. Anamnesis
1. Chief complaint
2. Current History

3. Past History

:
:
:
:
:
:
:
:
:
:

:
: EXAMPLE
Chest pain in the left and right side and in the epigastric
region, the patient put his hand in the heart region, since
1 hour ago, the pain began after he came from the toilet
at 02.00, the pain did not go away with resting, and
radiating to the back (upper) and then cold sweating,
nauseous, not vomiting, and felt weak in the bone almost
fainting. And then his family presented to the ER.
: EXAMPLE
Heavy smoker at least 1 pack/day since adolescence, quit
2 years ago after being diagnosed with light stroke in the
left arm.
Hypertension and hypercholesterolemia since 5 years
ago, without proper treatment. Sometime it reaches
200/100. Slight weak in the left arm 2 years ago,
diagnosed by a doctor but treated by traditional healer
and healed.

4. Family Illness History :

EXAMPLE - Parents : No stroke and heart attack, or
hypertension as far as he can remember. His daughter is also obese stage I.
5. Family Tree
: EXAMPLE - He is the oldest of 2, his younger brother had
hypertension.

6. System
: EXAMPLE
a. Cerebrospinal : Sometime headache but disappeared with ponstan,
vertigo : negative,
b. Cardiovascular : This is the first heart attack, tachycardia -, irregular
rythm -.
c. Respiratory
: dyspnoe-, cough -, postural dyspnoe : neg.
d. Gastrointestinal : Nauseous -, vomiting-, dyspepsia-.
e. Urogenital
: Urine clear, polyuria-, dysuria-.
f. Musculoskeletal : his left arm used to be weak, but healed completely.
g. Integument
:
h. Lymph nodes
: none
i. Eye
:
j. ENT
: None
7. Bio-Psycho-Social Background
EXAMPLE
Widower : lives with his daughter family, a bakmi food stall seller in front of
hospital where he is being admitted. His daughter family itself have a family
problem on her own: a drug addict son and the father is in jail.
8. Socio-economic Background :
EXAMPLE
Low income family, but not participant of Jamkesmas (national poverty health
insurance)
9. Environmental Background:
EXAMPLE
He lives in his daughters house, in a very crowded neighborhood.
10.Other Notes:

C. Physical Examination
1. General Appearance
:weak, pale, compos mentis, obese stage I.
2. Vital Signs
: BP 150/90
RR 24, regular
HR 65, regular, weak. T: 36.5 0t
3. Nutritional status : obese stage 1
Weight/Age
:
Height/Age
:
4. Head
: symmetric, haematoma -, conj : not pale,
Neck
: lymph node : -, JVP: normal, thyroid: not palpable/
Thorax
: Symmetric, , no retraction
Cardiac
: Ictus cordis :normal, S1-S2, murmur : negative. HR:
67/mnt, regular, pulse strong
Pulmonary
: Symmetric, , sonor +/+.no wheezing/rales

Abdomen
normal.
Extremity
+/+

: protuberance, tympani, tenderness : neg,peristaltic +

: symmetric, cold, pulse weak, odema neg/neg, strength:

D. Adjunct Examinations
1. Blood test
Hb
:
WBC
:
L/M/N/B/E
:
RBC
:
Platelet
:
Na
: NA
K
: NA
Cl
: NA
AST/SGOT
: NA
ALT/SGPT
: NA
2.
3.
4.
5.

Urinalysis
: NA.
Stool examination : NA
Rontgen
: NA
Other examination :
a. ECG : sinus rhythm, regular
1. HR:62 bpm
2. PR: 140 ms
3. QRS: 120 ms
4. QT: 400 ms
5. axis : 60 degr
6. RV5: 2 mV
7. S V1 : 0.5 mv
8. RV5+SV3 : 1mV
9. Abnormality :
a. ST elevation in lead II, III and avF
b. T inversion in lead I, avR,avL,V2,V3,V4
6. Oxygen Saturation : 99%.

E. Diagnosis
Working Diagnosis : EXAMPLE
1. ACS : Acute Myocardiac Infarct inferior, STEMI and Anterior
ischemic heart disease.
2. Hypertension stage I

Differential Diagnosis :
EXAMPLE
a. AMI right ventricle and inferior
b. IHD antero inferior
F. Therapy
1. Medication
: EXAMPLE
b. Oxygen 2 L/mnt
c. IVFD : D5% : 20 drops/mnt
d. Cedocard 5 ml Sublingual
e. Copidrogel 300 mg :oral
f. Cardioaspilet : 200 mg oral
2. Diet
:
a. Low salt diet.
3. Consultation with Internal medicine specialist : agree to the working
diagnosis, and therapy and suggested to be referred to Sarjito Hospital.
G. Patient Education and counseling
EXAMPLE

a. I am afraid I have bad news, This patient had very serious heart disease,
we suspect he had heart attack, that is an injured heart due to clot in his
heart blood vessels, so that his heart muscle did not received any blood
and eventually be injured and necrosis, and resulting in a weak heart. That
why he need to be treated promptly and efficiently.
b. In this hospital he received emergency treatment and it was given and
may relieve the symptoms. However he needs to be sent immediately to
the big hospital with facility of heart center such as Sarjito hospital.
c. Time is utmost important, to save his heart muscle, we call it time is
muscle, because the clot need to be opened as soon as possible within 3
hours, otherwise the heart muscle would not be recovered. The clot can
be opened in two ways, one by catheterization (that why he needed to go
to Sarjito hospital) and second by special injection to destroy the clot
(need a Heart specialist). Of course these two alternatives had their own
financial consequences. However since the patient had slight stroke and
sometime uncontrolled hypertension, there is a good evidence that
catheterization may be the better choice.
d. However, it has to be the patient and family decision whether or not you
agree to this suggestion.
H. Monitoring :

a.
b.
c.
d.

patient monitor
Print out : ECG every 6 hours.
X ray thorax
Blood anaylisis : lipid profile, SGOT/PT, Ureum creatinine, C-reactive
protein, Troponin, elektrolite : Kalium, natrium.

I. Prognosis : dubia due to acute coronary syndrome

hypertension, with history of stroke and heavy smoker.

with

co

morbid

J. SHORT TERM PLAN: Referral

a. Internal medicine specialist :
b. Referred to Cathlab Hospital : Heart Center Sarjito Hospital, but patient and
his family refused to the suggestion for financial reasons. To get a stent
operation his family needs to prepare at least 50 million rupiahs (or 5
thousand dollar). However, the family finally agreed to be sent to the district
hospital to be eligible for the local government health insurance for the poor.
K. LONG - TERM PLAN:
a. After referral (e.g. Home Visit, Home Care):

b. Targets and Commitments of Care-Plan:

c. Family Empowerment: