MORNING REPORT

Tuesday, 4th March 2014

Wahidin Sudirohusodo Hospital

Sheila Witjaksono
Titus Kurnia
Harie Cipta
Dian Pratiwi
Sitti Multa Zam

Patient identity
Name
: Mr. HN
Age
: 60 years old
Address : Tamangappa Raya
No. 325
MR
: 624107
Date of Admission : March
1st,2014

History Taking

A 60 y/o man, was referred from Ibnu Sina Hospital with NSTEMI
Chief complaint of shortness of breath
SOB (+) since a week ago worsen since last night, DOE (+), PND
(+), orthopnea (+), cough (+) with white mucous
Epigastric pain (+) since last night (+ 20 hours before), with
burning sensation accompanied by naussea with no vomiting.
History of chest pain since 3 days ago, pressed-like sensation
with duration less than 10 minutes, not radiated to back nor
upper limb, triggered by activity and relieved by rest and ISDN
SL. He had hospitalized last year and had accepted 5 days of
fondaparinux sub cutaneus injection. History of angiography
with Non significant LCX stenosis (on august 2013). In the last 3
months, he was not taking regular medication.
Cough (-), febris (-).
Micturation and defecation remains normal as usual. History of
black colouring stool (+) last year.

 History of HT (+), not taking regular treatment,

DM (-)
History of smoking (+) for >20 years, and had
stopped on day before admitted to the hospital
History of routine herbal consumption (dragon
fruit) since last year.
History of blood transfusion (+) >4 bag last
year.
History of blunt abdominal trauma a month
ago.

Physical Examination
General status: mod-ill/well-nourished/conscious
BP: 160/90 mmHg, P : 92 bpm (reguler), RR : 28tpm, T : 36,5
C
Conjunctiva anemic (+/+), icterus (-)
JVP R+3 cmH2O (30)
Vesicular breath sound, ronkhi (+) at mediobasal both of
lung
S 1/2 reguler, no murmur
Peristaltic (+), soepel (+), with tenderness on the all
abdominal region, especially on the epigastric region.
Hepar palpated 3 cm below arcus costa, unpalpated spleen
Lower extremity oedema (+/+) on the dorsum pedis, warm
acral
RT : Nipping sphincter, smooth mucosa, no palpable mass,
Handscoen : feces (+) with yellowish colouring, no blood nor
mucus.

ECG @ Ibnu Sina Hospital

Sinus rhythm , HR 95 x/minute, axis -20, P wave 0,08s, PR interval 0,16 s, QRS complex 0,08 s,
ST depression V4-V6
T-inverted I,aVL,V5-V6.RV5+SV2 = 39.
Conclusion: Sinus rhythm, normoaxis, Anterolateral ischemia,, LVH (+)

ECG

ECG @ ER

Sinus rhythm , HR 95 x/minute, axis -20, P wave 0,08s, PR interval 0,16 s, QRS complex 0,08 s,
ST depression V5-V6
T-inverted I,aVL,V5-V6.RV5+SV2 = 39.

CHEST X-RAY
Normal
bronchovascular
Cardiomegaly,
CTI 0,6
marking
Normal cardiac waist
NoSign
specific
process
on the
of pulmonary
oedema
(-)
both of lung
Cardiomegaly, CTI 0.62
with dilatation and
elongation of aorta
Normal sinus and
diaphragma
Intact bone
Conclusion:
Cardiomegaly with dilatatio
et elongatio aortae.
Atherosclerosis aortae.

3 position of BNO
Air on the instestine
distributed through
distal.
Intestinal loop not
dilated, no herring bone
appearance.
No sub diaphragm free
air.
Intact both psoas line
and peritoneal fat line.
Intact bone
Conclusion:
No sign of peritonitis at
the time x-ray taken.

Lab. Findings

WBC
: 13.5 x 103 /uL
HB : 4.9 mg/dL
MCV : 70 m3
MCH : 20 pg
MCHC : 27 g/dl
HCT : 18.5%
PLT : 547x 103 /uL
RBC : 3.45x 106 /uL
Ur : 36 mg/dL
Cr : 1.20 mg/dL
GOT : 11 mg/dL
GPT : 9 mg/dL

Trop. T
<0.01
CK
CKMB
RGB
PT
sec
aPTT
c 24.3 sec
INR
D-dimer

: Negatif
:
:
:
:

67.00 U/L
12.7 U/L
140 mg/dl
14.7 c 11.5
: 33.6

: 1.30
: 2.90

Assesment
CHF NYHA III ec HHD
Epigastric pain syndrome ec
suspecy drug gastropathy
CAD
Anemia mikrositik hipokrom ec ?

Management

O2 3-4 Lpm via nasal canule

IVFD NS 500 cc/24 hrs
Inj. Furosemide 40 mg/12 hours/IV
Captopril 3x12.5 mg
ISDN 5 mg SL
Transfussion of PRC 3 bag, 1 bag/day
Inj. Omeprazole 1 vial/ 12 hours/IV
Sucralfat syr 3x2 C

Plan
Blood smear analysis before
transfussion
USG Abdomen
Echocardiography

Patient identity
Name
: Mrs. H
Age : 61 years old
Address : Jl. Bonelengga
Caddika No. 12 Makassar
MR
: 653047
Date of Admission : March
1st,2014

History Taking
Patient was consulted from internal Department with
ACS, unconscious woman 61 years. She was referred
from RSUD Daya. She has been unresponded since
she was transported to the hospital. At the time she
arrived to RSUD Daya she was complained the chest
pain she felt since 12 hours before, pressed like
sensation, radiated to the back and the jaw,
accompanied by cold sweat and shortness of breath.
Her family denied the history of chest pain before.
History of HT (+), DM (+), not taking regular
medication.
History of smoking (-).

Physical Examination
General status: sev-ill/poornourished/unconscious
( GCS E1M1V1)
BP: undetectable, P : unpalpated, RR : (-)
Carotid artery : unpalpable
Conjunctiva anemic (-/-), icterus (-)
S 1/2 (-)
Extremity oedema (-/-), cold acral
ECG on monitor : Bradikardi HR 47

ECG

Assesment
Pulseless Electrical Activity

Management
Cardiopulmonary Resuscitation
CPR through 30 minutes, no response
Pupil total midriatic, no light nor
corneal reflex The patient died at
22.45 pm.