lapjag

1. Consultant in charge : Dr. dr. Masrul Syafri, Sp.PD, Sp.JP(K)
Resident in charge : dr. Hamzah/dr.Emelda/dr.Wenny/dr.Zakiy/dr.Fahrizal/dr.Alfi/dr.Shindu
EMERGENCY DUTY REPORT
Wednesday, April 14th 2021

2. Old Patients Patient New Patient Troubled Patient Died
CVCU Ward CVCU Ward Red Zone CVCU Ward CVCU Ward
- - - - - -

3. Patient Consult
No. Patient Diagnosis Governance
1.

4. New patients
1. Mrs. Nelwati/ 67 y.o.
/00.69.75.10
D /:
- Stable AF RVR
- CHF NYHA fc.III ec. CAD
- Sequele of ischemic stroke

5. Mrs. Nelwati/ 67 y.o./00.69.75.10
Chief complaint:
Palpitation since 2 hours before admission
Present illness:
• Palpitation (+) since 2 hours before admission , dizziness (-), syncope (-).
• Shortness of breath (+) since 1 weeks before admission, increased especially during
activities. History of DOE (-), PND (-), OP (-), ankle swelling (-), History of shortness of
breath (+) since 1 year ago. Patient was routinely controlled to Cardiologist and got
therapies furosemide, spironolactone, bisoprolol, ranitidine, atorvastatin.
• Chest pain (-), diaphoresis (-), nausea (-) and vomiting (-). History of chest pain (-).
• Patient got stroke since 3 weeks before admission, hemiparesis (+), slurred speech(+)
 Fever (-), Cough(-), diarrhea (-)

6.  Patient was referred from Cardiologist with diagnosed AF RVR
 At the ER: Palpitation (+), Shortness of breath (+)
Risk Factors:
• Menopause (+)
• HT(-)
• DM (-)
• Dyslipidemia(?)
• Family history (-)
Past ilness:
History of gastritis (+), Asthma (-), stroke (-),

7. Physical Examination
• General appearance : Moderate
• Sens : CMC
• Blood Pressure : 90/50 mmHg
• Pulse Rate : 110-120x/min, irregular
• Resp Rate : 22 x/m
• SpO2 : 98 % on O2 3lpm
• Neck : JVP 5+4 cmH20

8. Physical Examination
Pulmo:
insp : Symetric right = left
palp : Fremitus right = left
perc : Sonor right = left
ausc : Bronchovesicular, fine rales +/+ wet and soft in basal, wheezing -/-,
Cor :
insp : Ictus cordis not visible
palp : Ictus palpable at 1 finger lateral LMCS VIth ICS
perc : Upper : 2nd ICS
Right: LSD
Left : LMCS VIth ICS
ausc : S1N-S2N irregular, murmur (-), gallop (-)

9. Physical Examination
Abdomen
insp : Supel
palp : Hepar and lien was not palpable
perc : Tympani
ausc : Peristaltic sound (+) N
Extremities :
edema -/-, warm

10. ECG at Cardiologist (26/04/2021 at 05.06 pm)
AF SVR, QRS rate 110-120x/’, irregular, axis LAD, Pwave and PR int difficult to assessed, QRS dur 0,06s,
Tinverted at V5-V6, LVH(-), RVH(-), QTc 403msec

11. ECG at ER M.Djamil Hospital (26/04/2021 at 08.56 pm)
AF RVR, QRS rate 110-120x/’, irregular, axis LAD, Pwave and PR int difficult to assessed, QRS dur 0,06s,
Tinverted at V5-V6, LVH(-), RVH(-), QTc 403

12. 12
X-rays Thorax
CTR 86%, SgAo N, SgPo N, CW(+), apex downward, cranialization (0),
infiltrates (+)

13. Laboratory
• Hb : 13,4 mg / dL
• Ht : 40 %
• Leukocytes : 7.670 / mm3
• Platelets : 174.000/ mm3
• Sodium : 137 mmol / L
• Potassium : 4,0mmol / L
• Chloride : 109 mmol / L
• Calcium : 8,5 mg / dL
• RBG : 137 mg / dL
• Ureum : 71 mg / dL
• Creatinine : 1,0 mg / dL
• CCT : 51
• HbsAg : Non reactive
• Swab TCM : Negative

14. Blood Gas Analyze
• pH : 7,51
• pCO2 : 27,8
• pO2 : 168
• HCO3- : 22,6
• BE : -0,6
• SaO2 : 99,3%
• Respiratory Alkalosis

15. CHA2DS2VASc = 5
•CHF (+) : 1
•Hypertension (-) : 0
•Age (67 yo) : 1
•Diabetes (-) : 0
•Stroke (+) : 2
•Vascular (-) : 0
•Sex (female) : 1
•DM(-) : 0
HASBLED = 2
• Hypertension (-) : 0
• Abnormal ren/liver (-) : 0
• Stroke (+) : 1
• Bleeding (-) : 0
• Labile INR (-) : 0
• Drugs/Alcohol (-) : 0
• Age 67 yo : 1

16. Diagnosis
- Stable AF RVR
- CHF NYHA fc.III ec. CAD
- Sequele of ischemic stroke

17. Therapy at ER
• O2 3lpm
• IVFD RL 500cc /24hours
• Furosemide 40mg
• Swab TCM  If the result is negative  Admitted to Green Zone (CVCU)
Plan

18. Thank You