AF HF(Editted)

7/30/2019 AF HF(Editted)

1/17

MORNING REPORTSunday, August 5th, 2012

PHYSICIAN INCHARGE:

IA : dr. Eva, dr. Betty, dr. Yuli

IB : dr. Rusyda, dr. Fajarsari

II : dr. Nani Z.

III : dr. C. Singgih Wahono, SpPDMODERATOR: dr. Budi Darmawan, SpPD-KHOM


2/17

Summary of Data BaseMr. S/Male/55 y.o/W 24 B

Chief Complaint : chest pain

The patient suffered from chest pain since 5 hours before

admission, at the left area, heavy sensation, radiated to the

back, did not radiated to the jaw/left arm, lasted for 30

minutes, while patient was sleeping (at 4 oclock in the

morning). The complaint was accompanied by shortness of

breath. Actually, the patient has been suffering from shortnessof breath since one year ago, but it has got worsened since

the last two weeks. The shortness of breath occurred during

activities (walking more than 5 meters), and subsided during

rest.


3/17

The patient slept using 3 pillows, he often woke up

suddenly at night due to shortness of breath. He had

history of both leg swelling since months ago, and itsubsided by drugs prescribed by a mantri (the effect

of the medicines was increase of urination).

The patient complained about his urination, which

he experienced hesitation and dribbling at the end ofhis urination.

The patient also complained about abdominal pain,

especially at epigastric area, with burning andstabbing sensation

History of HT (+) 180/ mmHg, known since 6

months ago, but the patient did not routinely

consumed any particular medicines


4/17

Physical Examination

BP: 116/93 (ER)

120/80 mmHg

HR: 112 bpm (ER)

HR: 93 bpm (Ward); PR: 93 bpm

(irregular-irregular)

RR: 20tpm T.ax: 37 0C

General Appearance : looked moderately ill GCS : 456

BW: 46 Kg; BH 165 cm; BMI: 16.89 Kg/m2

Head Anemic conjunctiva(-) Icteric sclerae (-) LN enlargement (-)

Neck JVP : R + 2cm H2O; 300

Chest Heart Ictus visible and palpable at 6th ICS, 7 cm lateral from MCL S

(3cm of wide)

RHM 2 cm SL Dextra;LHM ictus

S1, S2 single, no murmur

Lung Symmetric; SF D=S; S| S V | V no additional breath sound

S| S V | VS| S V | V

Abdomen Flat, BS (N), Liver span68 cm, traubes space tympanic, soft,

tenderness (+) at epigastric area

Extremities Warm; Edema (-)


5/17

Laboratory FindingsLab Result Normal Value Lab Result Normal Value

Leukocyte 9.050 3,500-10,000/L Sodium 136 136-145 mmol / L

Hemoglobine 11.5 11.0-16.5 g/dl Potassium 3.50 3.5-5.0 mmol / L

PCV 34.3 35-50% Chloride 99 98-106 mmol / L

Thrombocyte 264,000 150,000-

390,000/l

RBS 135 > 200 mg/ dL

SGOT 43 11-41U/L Ureum 35 10-50 mg/dL

SGPT 30 10-41U/L Creatinine 1.04 0.7-1.5 mg/dL

Albumin 4.02 3.5-5.5 g/dL

05/08/2012

CK

CKMB

Trop I

160

44

0.50

39-308 U/L

7-25 U/L

(+)>1.0 U/L


6/17

Urinalysis

Lab Value Lab ValueSG 10 x

PH Epithelia

Leucocyte Cylinder

Nitrite Hyaline

Protein Granular

Glucose Leukocyte

Erythrocyte Erythrocyte

Keton urine 40 xUrobilinogen Erythrocyte

Bilirubin Leukocyte

Crystal

Bacteria


7/17

Blood Gas Analysis

Result Normal Value

pH 7.50 7.35 7.45

PCO2 41.7 35 45

PO2 147.7 80 100

HCO3 31.8 22 26

SaO2 99.1 90 100

BE 8.7 -3 -+3

Conclusion: metabolic alkalosis uncompensated + hyperoxemia


8/17


9/17


10/17

ECG Interpretation

HR 100 bpm

PR Interval: hard to be evaluated

QRS Complex: 0.06

QT Interval: 0.32 Frontal Axis: normal

Horizontal Axis: CWR

T inverted at V5-V6

QS pattern at V1+V2

Conclusion: AF 100bpm, ischemic at lateral wall,OMI anterior wall


11/17


12/17

X-RAY INTERPRETATION

AP position, symmetric, enough KV, enoughinspiration

Trachea: deviated t the right

Soft tissue: thin, and bone: normal Hemidiaphragma D:dome shape; coverewd by

cardiac imaging

Sinus phrenicocostalis D: sharp; S: cut by film

Pulmo : thickening of hillus D, BVP normal Cor : CTR 70%

Conclusion: cardiomegaly


13/17

CUE & CLUE PL IDx PDx PTx PMo

Male/55 YO

-left chest pain,

radiated to the back,

for 30 minutes-SOB;DOE;PND

-History of smoking

(+)

-History of HT (+)

-BP 120/80 mmHG

-HR112 93x/m

irreguler-irreguler

-RR 4018 tpm

-ECG: AF HR 110 bpm,

OMI anterior,

ischemia lateral wall

-CPK 160 U/L

-CKMB 4 U/L

-Trop I 0.5 U/L

1. Atypical

Chest

Pain

1.1 AF

1.2 GERD

-O2 8-10 LPM NRBM

-Bed rest

-Semifowler postiion

-Heart diet 1,700Kcal.Day, low sodium


14/17

CUE & CLUE PL IDx PDx PTx Pmo

Male/55 YO

-left chest pain,

radiated to the

back, for 30minutes

-SOB;DOE;PND

-History of

smoking (+)

-History of HT (+)

-BP 120/80

mmHG

-HR112 93x/m

irreguler-

irreguler

-RR 4018 tpm

-ECG: AF HR 110

bpm, OMI

anterior,

ischemia lateral

wall

2.Af RVR

NVR

2.1

dt.

No.1

-O2 8-10 LPM NRBM

-Bed rest

-Semifowler postiion

-Heart diet 1,700 Kcal.Day, lowsodium


15/17

CUE & CLUE PL IDx PDx PTx PMo

Male/55 YO

-SOB,DOE,PND

-History of leg swelling

-History of HT(180/mmHg)

-History of smoking

-BP 120/80 mmHG

-HR112 93x/m irreguler-

irreguler

-RR 4018 tpm

-ictus: 3cm wide, at ICS 6,

7cm lat from MCL Sx, RHM

2 cm lat from SL D

-CXR: cardiomegaly

3.HF

Stg. C

FC III

3.1 CAD

3.2 HHD

-Lipid profile

-Echo-

cardiography

-Bed rest,

semifowler

position

-Heart diet 1,700Kcal.Day, low

sodium


16/17

Condition This Morning

S:

GCS: 456

BP: mmHg

HR: bpm

PR: bpm

RR: tpm UOP: cc/H


17/17

THANK YOU

Documents

AF HF(Editted)