Duty report 2nd december 2015

1. DUTY REPORT
2nd December 2015
GP ON DUTY: DR. DEA & DR. ARDIAN
COASS ON DUTY: DONDYJULIANSYAH
EMERGENCY UNIT

2. PATIENT’S IDENTITY
Name : Mrs. L
Age : 41 years old
Religion : Moslem
Marital Status : Married
Address : ASR Rindam Jakarta Utara

3. 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

4. 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.

5. 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

6. HABITS AND LIFESTYLE
There were no history of smoking, alcoholic drinking, taking drugs
 Amlodipine 1 x 5 mg
PAST MEDICAL HISTORY

7. PHYSICAL EXAMINATION
VITAL SIGNS
General State : Moderate Sickness
Consciousness : Compos Mentis
Blood Pressure : 110/80 mmHg
Pulse : 102 x/minute
Respiratory Rate : 24 x/minute
Temperature : 36,2oC
Body Weight : 71 kg
Body Height : 160 cm
BMI : 27,73 (obese 1)

8. 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

9. 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

10. 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

11. ECG
 Sinus tachycardia, HR 125 x/minute, Left Axis
Deviation, PR interval 0,12 s, ST Depression on V2,
V3

14. Thorax X-Ray AP
no
cardiomegaly,
lungs within
normal limits

15. 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.

16. PROBLEMS LIST
 Unstable Angina Pectoris

17. ASSESSMENT
1. 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

18. THERAPY
Diagnostic Plan: ECG on serial,
Therapeutic Plan
IVFD RL 500 cc 20 tpm
Aspilet 4 x 80 mg
Clopidogrel 300 mg
ISDN 5 mg sublingual
Simvastatin 1x20 mg
Bisoprolol 1x2,5 mg

19. Sumber : ESC Guidelines for the management of acute coronary syndromes in patients
presenting without persistent ST-segment elevation. European Heart Journal (2011)

20. Sumber : Coronary Heart Disease in Clinical Practice

22. PROGNOSIS
 Qua ad vitam : Dubia
 Qua ad functionam : Dubia
 Qua ad sanationam : Dubia ad malam

23. THANK YOU