duty report ustable angina pectoris 2 12-15
TRANSCRIPT
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DUTY REPORT 2nd December 2015Unstable Angina Pectoris
GP ON DUTY: Dr. DEA & Dr ARDIANCOASS ON DUTY: DONDY & SISCASUPERVISOR : Dr SOROY LARDO SpPD FINASIMDEPARTMENT OF INTERNAL MEDICINEINDONESIA ARMY CENTRAL HOSPITAL GATOT SOEBROTO
EMERGENCY UNIT
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PATIENT’S IDENTITY
Name : Mrs. LAge : 41 years oldReligion : MoslemMarital Status : MarriedAddress : ASR Rindam Jakarta
Utara
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ANAMNESIS
Autoanamnesis on 2nd December 2015 at 9 PM
Chief Complaint : Chest pain at the left for 3 days before admission
Additional Complain: Nausea, Cold sweating
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CURRENT ILLNESS
The patient, female, 41 years old, was admitted at emergency room with chest pain for 3 days. Chest pain was at the left and radiated to the left shoulder and back. The characteristic of pain was like being crushed and heavy. It was improved with rest and got worsen with activity. The duration of chest pain was more than 35 minutes. There were nausea but no vommiting. There were also excess of cold sweating. Patient also complained of lacking of sleep for 3 days due to the chest pain. There was no breathlessness. There were no DOE, ortopnea, and PND.
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PAST ILLNESS
There was controlled Hypertension There was controlled DM with Metformin 3
times a day
Heart Disease from Mrs. L’s Father Diabetes denied Malignancy denied Stroke denied
FAMILY ILLNESS
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HABITS AND LIFESTYLEThere were no history of smoking, alcoholic drinking,
taking drugs
Amlodipine 1 x 5 mg
PAST MEDICAL HISTORY
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PHYSICAL EXAMINATION
VITAL SIGNSGeneral State : Moderate SicknessConsciousness : Compos MentisBlood Pressure : 110/80 mmHgPulse : 102 x/minuteRespiratory Rate : 24 x/minuteTemperature : 36,2oCBody Weight : 71 kgBody Height : 160 cmBMI : 27,73 (obese 1)
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PHYSICAL EXAMINATION
General Examination Head : Normocephal
Eye : anemic conjunctiva (-/-), icteric sclera (-/-) Ears : normotia, discharge (-) Nose : septum deviation (-), discharge (-) Mouth : oral trush (-), leukoplakia (-)
Neck : lymph nodes enlargement (-) Thorax : symmetric, intercostal retraction (-)
Cor : regular 1st and 2nd heart sound, murmur (-), gallop (-) Pulmo : vesicular breathing sounds, ronki (-/-), wheezing (-/-)
Abdomen : distended (-), bowel sound within,normal limit, timpani, hepar & lien not palpable, absence of pain
Extremities : warm, pitting edema (-), clubbing (-), cyanosis (-) CRT < 2 seconds
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DIAGNOSTIC PLANS
RESULT NORMAL RANGE
Hematologi rutin:
Hb 16 13 - 18 g/dl
Ht 46 40 – 52 %
Erythrocyte 5.4 4.3 - 6.0 mil /ul
Leukocyte 10100 4800 – 10800/ul
Thrombocyte 282000 150000 - 400000/ul
MCV 88 80 – 96 fL
MCH 29 27 - 32 pg
MCHC 35 32 – 36 g/dL
LABORATORIUM
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RESULT NORMAL RANGE
Kimia klinik:
CPK 89 26 – 140 U/L
CK-MB 12 7 – 25 U/L
Ureum 22 20 - 50 mg/dl
Creatinin 0,8 0.5 – 1.5 mg/dl
Random Blood Glucose 124 < 140 mg/dl
Natrium 139 135 – 147 mmol/L
Kalium 3.7 3.5 – 5.0 mmol/L
Klorida 101 95 – 105 mmol/L
IMUNOSEROLOGI
Troponin I (rapid) -/Negatif -/Negatif
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ECG
Sinus tachycardia, HR 125 x/minute, Left Axis Deviation, PR interval 0,12 s, ST Depression on V2, V3
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Thorax X-Ray AP
no cardiomegaly, lungs within normal limits
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RESUME
The patient, female, 41 years old, was admitted at emergency room with chest pain for 3 days. Chest pain was at the left and radiated to the left shoulder and back. The characteristic of pain was like being crushed and felt heavy. It was improved with rest and got wersen with activity. The duration of chest pain was more than 15 minutes. There were nausea but no vommiting. There were also excess of cold sweating. On physical examination, heart rate is 102x/minute. The laboratory within normal limit. CPK, CK-MB, Troponin I were within normal limit. ECG showed LAD, ST depression on V2 & V3, Thorax X-Ray was within normal limit.
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PROBLEMS LIST Unstable Angina Pectoris
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ASSESSMENT1. Unstable Angina Pectoris
Anamnesis: The patient, female, 41 years old, was admitted at emergency room with chest pain for 3 days. Chest pain was at the left and radiated to the left shoulder and back. The characteristic of pain was like being crushed and heavy. It was improved with rest and got wersen with activity. The duration of chest pain was more than 35 minutes. There were nausea but no vommiting. There were also excess of cold sweating. There was history of uncontrolled hypertension and medication
DD: NSTEMI ECG: ECG showed ST depression on V2 & V3. But no increase of CPK,
CK-MB
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THERAPY
Diagnostic Plan: ECG on serial,Therapeutic Plan
IVFD RL 500 cc 20 tpmAspilet 4 x 80 mgClopidogrel 300 mg ISDN 5 mg sublingualSimvastatin 1x20 mg Bisoprolol 1x2,5 mg
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Sumber : ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal (2011)
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Sumber : Coronary Heart Disease in Clinical Practice
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PROGNOSIS
Qua ad vitam : Dubia Qua ad functionam : Dubia Qua ad sanationam : Dubia ad malam
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THANK YOU