AF duty report

1. Emergency Duty Report
Wednesday, February 3rd
2021
Consultant incharge : dr. Hauda El Rasyid, Sp.JP (K)
Residen incharge : dr. Putri H/dr. Deddy/dr. Gio/dr. Medika/ dr. Andre

2. Old Patient New Patient Problemed Died
CVCU Ward CVCU Ward YZ CVCU Ward CVCU Ward
5 10 - - 1 - - - -

3. Patient in consult
Patient Diagnosis Treatment
1 Mrs. Yarinisa/ 36 y.o/
01.09.84.70
• Severe Preeclampsia with
P2A0H2 post partum
pergvaginam
• Metyldopa 3x250mg if TDS 140 mmHg,
TDD >90mmHg. Regimen MgSO4 baased
on Obgyn procedures
2 Mr. Syafriadi/ 01035578 Pericardial Effussion without
tamponade
• No therapy
3. Mrs. Ermawati/ 62 y.o/
00.85.26.21
• ADHF wet and warm on
CHF ec. CAD, HHD
• Ascites ec. susp. Cardiac
cirrhosis
• Pleural Effusion bilateral
• Mild anaemia ec chronic
disease
• Trombocytopenia ec.
Cirrhosis
• Hypoalbuminemia ec.
Cirrhosis
• Hypocoagulation
• Lasix 2x20mg

4. New Patient
1. Mr. Epi Vernando, 48 y.o
 AF Normo Ventricular
Response with flutter episode
 Hypercoagulopathy
 Old Stroke
 Susp covid 19

5. Mr. Epi Vernando, 48 y.o,
Chief Complain : Limb weakness since 25 days before admission
Recent history illness
 Limb weakness on the left side since 25 days before admission, the
patient cant talk but still understand and can follow a simple instruction,
Headache (-), seizure(-). This complaint felt first time 25 days ago and the
patient go to RSUD M.Natsir and referred to RS Yos Sudarso, hospitalize
for 12 days. After that, the patient got hospitalized again in RSUD
M.Natsir Solok because there is still no improvement in symptoms. And
hospitalized for 10 days. His family forgot the medicines which he took.
 Chest discomfort (-), diaphoresis(-), nausea(-), vomit (-), history of chest
pain(-)
 Palpitation(-), sudden dizziness(-), loss of consciousness(-)
 Productive cough since 1 week before admission, fever (-), difficulties in
breathing(-)
5

6. Risk factor of CAD :
- Smoker (+) 20 years, 1-2 pack/day
- Hypertension (+) for 10 years, uncontrolled
⁻ DM (-)
⁻ Dyslipidemia (-)
⁻ FH (-)
⁻ Dyslipidemia
Past history illness
Stroke (+) since 25 days before admission, well controlled,
Asthma (-), Gastritis (-),
6

7. Physical Examination
General appearance : Moderate
Consciousness : CM aphasia
Blood Pressure : 112/80 mmHg
Pulse Rate : 82x/m, regular
Temperature : 36.7 oC
Resp Rate : 20 x/m
Eye : conjunctica not pale,
sclera not yellowish
7

8. Pulmo:
insp : Symetric right = left
ausc : Vesicular, rales -/-, wheezing -/-
Cor :
insp : Ictus cordis was not visible
ausc : S1-S2, irregular, Murmur(-) and gallop (-)
8

9. Abdomen
insp : Supel
ausc : Peristaltic sound (+) N
Extremities :
Edema -/-, warm
Motorik : 555/333
555/333
9

10. ECG at ED 4/2/2021 22.21 WIB
AF,QRS Rate 70x/I, P wave and PR Int cant defined, QRS dur 0.06s, ST elevation 1mm in aVR, ST
depression in V3-V6, aVF, LVH(-), RVH(-)
10

11. Chest
X-Ray
CTR 64%, Sg Ao N, Sg Po N, CW (+), infiltrate (+),
cranialization (-)

12. Echocardiography Bed side
12

13. Laboratory Findings
 Hb : 15.3 mg/dl
 Leucocyte : 15.650/mm3
 Ht : 43 %
 Platelet : 362.000/mm3
 Na/K/Cl/Ca : 139/4.2/105/8.7
 Ur/Cr/CCT : 20/0,5/111
 Blood gas analysis : PH/PO2/PCO2/HCO3/BE/Sat O2 :
7.48/84/38/28.4/4.7/98
13

14. 14
• Troponin I : 398 ng/L
• HbSAg : Non Reaktif
• PT/APTT/INR : 11.4/21.6/1.03
• SGOT/SGPT : 32/11,4
• GDS : 92
• D Dimer : 2227

15. CHADS2 VASc Score : 3
15
 Congestive HF : 0
 Hypertension : 1
 Age 48 yo : 0
 DM : 0
 Prior TIA or stroke : 2
 Vascular disease : 0
 Age 48 : 0
 Sex category Male : 0

16. HASBLED : 2
16
 Hypertension : 1
 Abnormal renal/liver failure : 0
 Stroke : 1
 Bleeding tendency : 0
 Labile INR : 0
 Age 48 yo : 0
 Drugs : 0

17. Working diagnose
17
 AF Normo Ventricular Response with flutter episode
 Hypercoagulopathy
 Old Stroke
 Susp covid 19

18. Therapy in ED
18
 Therapy
 O2 NC 3lpm
 IVFD RL 500cc/24 hours
 Plan
 Pulmonologist department consult
 Neurology consult

19. Consult (Pulmonology)
19
 A/ Susp Covid 19
 AF NVR
P/ Swab isothermal at Emergencies, if positive patient transferred
to Red Zone, if negative, patient transferred to Green Zone
Azithromicyn 1x500mg, Vit C 2x250mg, Zinc 2x20mg, N
Acetilsistein 2x200mg

20. Consult (Neurology)
20
 A/ Old Stroke
 AF NVR
 Advice : ASA 1x80mg
 There is no contraindication to give anticoagulant in patient

21.  Therapy:
 O2 3 lpm
 IVFD RL 500 cc/24
hours
 Plan:
 Heparinisasi
 Bisprolol 1x2,5mg

22. Thank You
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