Morning Report

1. Morning Report
Sunday, 23th October 2022
Fathlina
Mardhiyah
Winona
Archie
Mia
Ilzy
Jordy
Jauhar
Endang (interna)

2. 2
No Identity Diagnosis
1. Mr. MSN/ 06-08-1960/ 62 years
old/ RM 938518
• Congestive Heart Failure NYHA III
• Coronary Artery Disease 3 Vessel Disease
• Diabetic Mellitus type 2
2. Mr. M/ 31-12-1954/ 68 years
old/ RM 978762
• Congestive Heart Failure NYHA III
• Severe Aortic Regurgitation
• Elevated Liver Enzyme
• Acute Kidney Injury DD/ Acute on CKD
• Hypoglycemia (65)

3. 1st Patient Identity
Name : Mr. MSN
Age : 62 years old
Date of Birth : 06-08-1960
Address : Makassar
MR : 938518
Date of Admission : October 23th 2022
DPJP : dr. Muh. Asrul Apris, Sp.JP (K)

4. History Taking
Chief complaint : Shortness of breath
• SoB was felt since 1 month ago, intermittently, worsening 3 days prior to admission.
DOE (+), PND (+), Orthopneu (+). History of shortness of breath (+).
• Chest pain (-). History of intermittent chest pain (+), relieved during rest.
• Palpitation (-), history of palpitation (-)
• Patient had history of cardiac catheterization in 2018 at Gatot Subroto Hospital,
Jakarta, and was advised for bypass surgery but he refused. He didn’t bring the
result.
• The patient routinely controlled at Cardiac Centre Policlinic and get Ramipril 2.5 mg,
Clopidogrel 75 mg, Spironolactone 25 mg, Bisoprolol 2.5 mg, Atorvastatin 20 mg,
furosemide 40 mg, Lantus 16 IU, Novarapid 8 IU
Coronary risk factors :
• History of hypertension (+), since 5 years ago, take Ramipril 2.5 mg routinely
• History of Diabetes Mellitus (+), since 7 years ago, routinely took Insulin
(Novorapid 3x8 IU, Lantus 16 IU)
• History of smoking (+) for 20 years, 1 pack/day, stopped 3 years ago
• No family history of Cardiovascular disease.

5. Physical Examination
• BP: 120/71 mmHg, HR : 82 bpm regular, RR : 24 tpm,
T: 36.5 0C
• Conjunctiva not anemic, sclera not icteric
• JVP R+3 cmH2O
• Vesicular breath sound, rales on basal bilateral,
wheezing (-)
• S1/S2 regular, murmur (-)
• Oedema (+) minimal, warm extremities, CRT <2 sec.

6. ECG Cardiac Centers
23/10/2022
Sinus rhytm, HR 72 bpm, regular, axis -35, p wave 0.08 sec,
PR interval 0.16 sec, QRS duration 0.10 sec, LVH (cornell
criteria R AVL + S V3 > 28 mm, T inverted I AVL, V5, V6
Kesan: SR, LAD, LVH, lateral wall myocardial ischemia

7. Lab Findings at Cardiac Center
(October 23th 2022)
eGFR : 54.5
ml/min/1.73m2
NLR: 7.46

8. X-Ray Thorax
October 23th 2022
CTI 0.59

10. Echocardiography Bedside
May 29th 2022

17. Echocardiography Bedside
23-10-2022
• Moderately abnormal LV systolic function, EF 33.1%
(TEICH), 30.8% (Biplane)
• Normal RV systolic function, TAPSE 1.73 cm
• Moderate MR, moderate TR, moderate PR
• Mild AR
• All cardiac chambers dilatation
• Eccentric LVH
• Akinetic & hypokinetic segmental
• eRAP 15 (2.3/1.8 cm)
• Grade III LV diastolic dysfunction

18. Working Diagnosis
• Congestive Heart Failure NYHA III
• Chronic Coronary Syndrome Clinical Scenario 4
• Type 2 Diabetes Mellitus

19. Management
• IVFD NaCl 0.9% 500 cc/ 24 hours/ intravenous
• Furosemide 40mg/8 hours/intravenous
• Spironolactone 25mg/24 hours/oral
• Ramipril 2.5 mg/ 24 hours /oral
• Clopidogrel 75mg/24 hours/oral
• Atorvastatin 20mg/24 hours/oral
• Isosorbide dinitrate 5 mg/ sublingual (if chest pain)

20. PLAN
• Monitoring vital sign and hemodynamic
• Monitoring urine output and fluid balance
• Swab Antigen
• Transfer to ward if swab is negative
• Consult to Endocrine Metabolic

21. Endocrine Metabolic Division
Diagnosis:
Management:
Plan:

23. 2nd Patient Identity
Name : Mr. M
Age : 68 years old
Date of Birth : 31-12-1954
Address : Makassar
MR : 978762
Date of Admission : October 23th 2022
DPJP : dr. Muh. Asrul Apris, Sp.JP(K)

24. History Taking
Chief complain : Shortness of breath
• Experienced since a week ago, worsening 1 day prior to admission. DOE (+), PND
(+), Orthopneu (+). History of shortness of breath (+) intermittently since 6 months
ago.
• Chest pain (-), no history of chest pain.
• Palpitation (-), no history of palpitation.
• Patient also felt bloated, nausea, and vomit twice food- contained, before came to
the ER.
• Patient routinely controlled at Cardiac Centre Policlinic with Severe Aortic
regurgitation and regularly took Ramipril 5 mg, bisoprolol 2.5 mg, and furosemide
40 mg.
Coronary risk factors :
• History of hypertension (+), since 6 months ago, regularly take medication,
• No history of Diabetes Mellitus,
• No history of smoking,
• No family history of Cardiovascular disease.

25. Physical Examination
• BP: 148/64 mmHg, HR : 81 bpm regular, RR : 24 tpm,
T: 36.5 0C
• Conjunctiva not anemic, sclera not icteric
• JVP R+3 cmH2O
• Vesicular breath sound, rales on basal bilateral,
wheezing (-)
• S1/S2 regular, murmur diastolic grade 2/4 in ICS III-
IV LSB
• Oedema (+) minimal, warm extremities, CRT < 2 sec.

26. ECG Cardiac Centers
23/10/2022
sinus rhythm, HR 83 bpm, regular, axis 56, LVH (sokolow lyon: S V1 + R V5-V6 > 35 mm ),
no ST-T wave changes
Kesan: SR, normoaxis, LVH, no ST-T wave changes

27. Lab Findings at Cardiac Center
(October 23th 2022)
eGFR : 22.7
ml/min/1.73m2
NLR: 22.02
144 mg/ dl

28. X-Ray Thorax
October 23th 2022
CTI 0.56

30. Echocardiography Bedside
May 29th 2022

37. Echocardiography Bedside
23-10-2022
• Normal LV systolic function, EF 65.8% (TEICH), 61.0%
(Biplane)
• Normal RV systolic function, TAPSE 1.94 cm, S’ lat 11.3
cm/s
• Severe AR
• Mild MR, Mild TR, Mild PR
• LV dilatation
• Concentric LVH
• Global normokinetic
• eRAP 8 mmHg (1.9/1.0 cm)

38. Working Diagnosis
• Congestive Heart Failure NYHA III
• Severe Aortic Regurgitation
• Elevated Liver Enzyme
• Acute Kidney Injury DD/ Acute on CKD
• Hypoglycemia (65)
• Dyspepsia

39. Management
• IVFD NaCl 0.9% 500 cc/ 24 hours/ intravenous
• Dextrose 40% 50 cc/ intravenous/ extra
• Furosemide 40mg/12 hours/intravenous
• Ramipril 5 mg/ 24 hours /oral
• Omeprazole 40 mg/ 24 hours/ intravenous

40. PLAN
• Monitoring vital sign and hemodynamic
• Monitoring urine output and fluid balance
• Swab Antigen
• Transfer to ward if swab is negative
• Consult to GEH and GH Divisions

41. Endocrine Metabolic Division
Diagnosis:
Management:
Plan:

42. Nephrology Division
Diagnosis:
Management:
Plan:

43. Thank You