Morning Report

Tuesday, April, 23rd 2019

Date : April 23rd , 2019

Member of Presenter
201820401011131 Rafdian Janitra Hadi

201820401011132 Wiby Fahmi Wijaya

201820401011146 Neny Ariana Usman

MR Consultant : dr. Vitriyaturrida, SpJP

Subjective (Apr 22rd, 2019) Objectives
Mrs. S/ 72nd y.o/437225 Physical Examination
Chief complaint : Heart palpitation
Patient was referred from PKM Larangan, with diagnosed Vital signs
Hipertension crisis with arrhythmia. GCS 456
BP 202/115 mmHg
Patient suffered from heart palpitation since a week before HR 100 tpm
admission, accompanied with Lethargy and dyspnea. RR 24 tpm
Dyspnea getting worse after doing activity. Then she was SpO2 97% on NC 4 lpm
brought to the PKM Larangan at 10.30, was diagnosed as
Hipertension crisis with arrhythmia and given loading RL Head/Neck
captopril 50mg sublingual and O2 nasal canule, than Conjuctiva pale -/-, icteric sclera -/-
referred to the RS SMART at 13.00 cause the hipertension JVP R+ 0 cm H2O (45 deg)
still persisted. Thorax
Cor: Ictus cordis invisible, palpable at ICS VI
History of orthopneu (-), PND (+), syncope (+) at 9.00 am, S1-S2 irregular, murmur (-), gallop (+)
leg swelling (-). Pulmo: symmetrical, rh -/-,wh -/-
-/-
When she was arrived at RS SMART, he still complained of -/-
heart palpitation and lethargic. Abdomen :
Soefl, tenderness(-), BS (+) N
History of HT (+) since 3 years ago routinely controlled, DM
(-) , astma (-), dislipidemia (-) Extremities
Edema -/-, warm acral
Family history of cardiovascular disease was unknown -/-
ECG I at ER RS SMART, April, 22nd 2019; 13.30
CXR, December , 7th 2018
• 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 67 %
• Cardiac waist (-)
• Apex Hipertrophy
• Hemidiaphragm:
• R: dome-shaped
• L: dome - shaped
• Costophrenic angles: right – left
sharp
• Pulmo: Normal

• Conclusion
• Cardiomegaly
 Laboratory Finding

Date: April, 22nd 2019, 14.25

Parameter Result Normal Value

Hb 13.3 g/dL 13.4 – 17.7 g/dL

Leukocytes 6.490 /µL 4300-10300/µL

Hematocrit 39.7 % 40 – 47 %

Thrombocytes 254.000 /µL 142000-424000/µL

MCV 89.0 fL 80 – 93 fL

MCH 29.8 pg 27 – 31 pg

MCHC 33.5 g/dL 32-36 g/dL

Random Blood Sugar 103 g/dL <200 mg /dl

 ASSESSMENT TREATMENT
1. Heart Failure class II Planning Diagnosis :
2. HT Crisis Serial ECG, Echocardiography,
Serial cardiac enzyme, serial DL,

Planning Therapy :
Bedrest
O2 NC 2-4 lpm
Infus PZ 0.9 % 500 cc/24 hour
Inj. Diltiazem 0,25mg/kg in 2 minutes
Inj. Furosemid 3x1 ampul (10mg/ml).6cc SC
Peroral :
Telmisartan 1x80mg
Clopidogrel 1x75 mg
Spironolakton 1x25 mg

Asking for advice from Cardiologist

Admitted to Ward
 TIMELINE

• Female, 72 yo At 10.30 a.m

• HT crisis
• Heart palpitation
• Dyspnea
• Referred to
• Syncope + , at 9.00
RSSMART
am
• Brougth to PKM
Larangan and got
medication, but
didn’t feel better At 13.00 pm

Risk factors
 Physical Examination
BP 202/115 mmHg HR 100 bpm regular RR 24 tpm SpO2 97 % on O2
nasal canul 4 lpm
General appearance looked moderately ill GCS 456 VAS 1/10

Head Pale conjungtiva (-) Icteric (-)

Neck JVP R+0 cm H2O; 45
Thorax: Cor: Cor: Ictus cordis invisible, palpable at ICS VI MCL S
Heart sounds S1-S2 irregular, murmur (-), gallop (+)

Lung: Symmetric Rh - - Wh - -
- - - -
- - - -
Abdomen soefl, shifting dullness (-), epigastric tenderness (-), normal bowel
sound
Extremities Edema - -
- -
Therapy ICU
• PZ 7 TPM
• Inj. Herbesser 0,25 mg/kg in 2 minutes, continued
pump 5 mg/hr.
• Inj. Ranitidine 2 x 1 (IV)
• Inj. Furosemide inj. 3x1 (IV)
• Clopidrogel 1x75 mg (P.O)
• Spirolonacton 1x25mg (P.O)
• Micordis 1 x 80 mg (P.O)
Condition the of duty
• S: heart palpitation (-), chest discomfort subsided
• O:
• BP 186/123 mmHg
• HR 135 bpm
• RR 30 x/min
• Tax 37.1 degrees C
• SpO2 99 % NC 4 lpm
• Urine output : 100 ml/h
Condition this morning
• S: chest pain (-), chest discomfort subsided
• O:
• BP 150/85 mmHg
• HR 80 bpm
• RR 17 x/min
• Tax 36.9 degrees C
• SpO2 99 NC 4 lpm
• Urine output 1500 ml/ 24h
ECG this morning
THANKYOU
 GRACE
Score 63