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    Duty Report Muzaini UAP

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    Ainil Mardiah
    1) Mr. Muzaini, a 65-year-old male, presented to the emergency room with chest pain for 10 hours. 2) He has a history of heart disease including prior stent placements and is being treated for hypertension and diabetes. 3) In the emergency room, his ECG, labs and chest x-ray were unremarkable. He was diagnosed with unstable angina and given various medications to treat his symptoms and manage his conditions.

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    Duty Report Muzaini UAP

    Uploaded by

    Ainil Mardiah
    27 views29 pages
    1) Mr. Muzaini, a 65-year-old male, presented to the emergency room with chest pain for 10 hours. 2) He has a history of heart disease including prior stent placements and is being treated for hypertension and diabetes. 3) In the emergency room, his ECG, labs and chest x-ray were unremarkable. He was diagnosed with unstable angina and given various medications to treat his symptoms and manage his conditions.

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    1) Mr. Muzaini, a 65-year-old male, presented to the emergency room with chest pain for 10 hours. 2) He has a history of heart disease including prior stent placements and is being treated for hypertension and diabetes. 3) In the emergency room, his ECG, labs and chest x-ray were unremarkable. He was diagnosed with unstable angina and given various medications to treat his symptoms and manage his conditions.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    27 views29 pages

    Duty Report Muzaini UAP

    Uploaded by

    Ainil Mardiah
    1) Mr. Muzaini, a 65-year-old male, presented to the emergency room with chest pain for 10 hours. 2) He has a history of heart disease including prior stent placements and is being treated for hypertension and diabetes. 3) In the emergency room, his ECG, labs and chest x-ray were unremarkable. He was diagnosed with unstable angina and given various medications to treat his symptoms and manage his conditions.

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    Emergency Duty Report

    Wednesday, August 12th

    2020
    Consultant incharge : dr. Kino, SpJP (K)

    Residen incharge : dr. Putri Handayani/ dr. Deddy/ dr. Sisca/ dr.
    Riski/ dr. Medika
    Old Patient New Patient Problemed Died

    Yellow
    CVCU Ward CVCU Ward CVCU Ward CVCU Ward
    Zone

    3 8 2 - 2 - - - -
    Patient in consult

    Patient Diagnosis Treatment


    1 Naimah, 80 y.o, • HT Stg II • Amlodipin 1x5mg (morning)
    00.09.70.83 • Aspiration Pneumonia • Candesartan 1x8mg (night)
    • Sequele ischaemic
    stroke
    New Patient
    Mr. Muzaini/ 65 y.o/ 00.30.33.10
    UAP timi 4/7, GS 87
    ASHD post PTCA 1 stent in prox-mid
    LAD (2017), 1 stent in prox-mid LCX
    (2018), 1 stent in mid-distal LAD (2018)
    HT stg II
    Type II DM
    PATIENT WILL BE REPORTED
    Mr. Muzaini/ 65 y.o/ 00.30.33.10
    Chief complaint
    Chest pain since 10 hours before admission

    Present Illness
    Chest pain since 10 hours before admission, in the middle of chest, duration < 30 minutes, radiation (-), diaphoresis
    (-), nausea (+) and vomiting (-). History of chest pain (+) 1 stent in prox-mid LAD (2017), 1 stent in prox-mid LCX
    (2018), 1 stent in mid-distal LAD (2018). Patient routinely controlled with cardiologist and got therapy bisoprolol
    1x5mg, amlodipine 1x5mg, ASA 1x100mg, Imidapril 1x5mg, Short acting insulin 1x12 IU, Long acting insulin 3x12
    IU.
    Shortness of breath (-). DOE (-), OP (-), PND (-), leg swelling (-)

    Palpitation (-), dizziness (+) since 3 hours before admission, syncope (-).
    Patient was referred from SPH and diagnosed with UAP and already got therapy Enoxaparin 2x0.6cc, ASA 1x100mg,
    Bisoprolol 1x7.5 mg, Amlodipin 1x10mg, Imidapril 1x10mg, NTG 20mcg/min, Short acting insulin 1x12 IU, Long
    acting insulin 3x12 IU, Lansoprazole 1x30mg.
    At emergency : chest pain (+) with scale 2/10

    Risk factors
     Ex Smoker (+), stop smoking since 2 years ago
     Hypertension (+) since 10 years ago controlled with amlodipine 1x10mg, imidapril 1x10mg
     DM (+) >5 years ago, controlled by insulin
     FH (-)
     Dislipidemia (?)

    Past Illness
    asthma (-), gastritis (-), stroke (-)
    Physical Examination
    General appearance : Moderate
    Sens : CMC
    Blood Pressure : 158/85 mmHg
    Pulse Rate : 66 x/min
    Resp Rate : 20 x / m
    Neck : JVP 5+0 cmH20
    SaO2 : 98 % Room Air
    Pulmo:
    insp : Symetric right = left
    palp : Fremitus right = left
    perc : Sonor right = left
    ausc : Vesiculer (+), rales -/-, wheezing -/-

    Cor :
    insp : Ictus cordis not visible
    palp : Ictus cordis palpable at LMCS 5th ICS
    perc : Upper : 2nd ICS
    Right: LSD
    Left : at LMCS 5th ICS
    ausc : S1N-S2N reguler, murmur -, gallop -
    Abdomen
    insp : Supel
    palp : Hepar and lien was not palpable
    perc : Tympani
    ausc : Peristaltic sound (+) N

    Extremities :
    Edema -/-, warm
    ECG at ER (13/8/2020 )

    SR, QRS rate 60 x/m , Axis LAD, P wave N, PR int 0,16 s, QRS dur 0,06s,
    ST – T change (-), LVH (-), RVH (-)
    Laboratory Findings
    Hb : 13.5 g/dl Ur/Cr : 28/1 mg/dl

    Leucocyte : 11.730 /mm3 CCT : 63

    Ht : 40 % RBG :
    314mg/dL
    Platelet : 274.000 /mm3
    Trop I : 22 ng/L
    Na/K/Cl/Ca : 140/3.7/107/8.1
    BGA
    pH : 7.41
    pCO2 : 33
    pO2 : 168
    HCO3 : 20.9
    BE : -3.7
    SAO2 : 100%

    Normal BGA
    Chest X-Ray

    CTR 58% , Sg Ao N, Sg Po N , CW (+ ), apex downward, cranialization(-), infiltrate (-)


    CTR 58% , Sg Ao N, Sg Po N , CW (+ ), apex downward, cranialization(-), infiltrate (-)
    TIMI RISK
     Age 65 yo : 0
     >3 FR (+) : 1
     CAD (+) : 1
     Biomarker (-) : 1
     ST segment deviation (-) : 0
    4/7
     Angina (-) : 0
     ASA 7 days (+) : 1
    GRACE SCORE
     Age 65 yo : 53
     HR 66 : 0
     TDS 158 : 26
     Killip I: 0
     Cr 1.0 : 8
     Cardiac Arrest (-) : 0
     Biomarker (-) : 0
     ST-T changes (-) : 0

    87
    DIAGNOSIS
    ◦ UAP TIMI 4/7 GS 87
    ◦ ASHD post PTCA 1 stent in prox-mid LAD (2017), 1 stent in prox-mid LCX (2018), 1
    stent in mid-distal LAD (2018)
    ◦ HT stg II
    ◦ Type II DM
    Therapy in ER
    NTG 20 mcg

    Enoxaparin 2x0.6cc

    ASA 1x100mg

    CPG 1xx75mg

    Bisprolol 1x25mg

    Amlodipin 1x10mg

    Imidapril 1x10mg

    Glyceryl trinitrate 2x2.5mg

    Criticall ill insulin


    Plan
    Consult to DPJP Covid  Greenzone
    Consult to Internal medicine
    Profil lipid test
    Keton urine test
    TERIMA KASIH

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