MORNING

REPORT
NIGHT SHIFT TEAM :
VERLITA - TITA
 Patient Identity
Name : Mr. S

Age : 45

Sex : Male

Med Rec : 6754xxx

Address : Karangjati, Ngawi

Date of entry : November 21, 2018

History of Present Illness
 Chief Complains
Presented with 3 days of chest pain
 History of Present Illness
A 45 years old man comes in emergency complaining of chest pain. For
the last 3 days, he has had intermittent nocturnal chest pain that last up
to ten minutes. The pain is substernal and radiates to his back and
always wakes him up from sleeping. No nausea and shortness of breaths
are stated.
Past Medical History
 Hypertension (-)
 Diabetes Mellitus (-)
 Obesity (+)
 Dyslipidemia (+)
 Hyperuricemia (-)
 Allergies (-)

Family History
Nobody has any long-term health problems, health issues, and serious illnessess

Social History
 Not physically active
 High fat diet
Summary

Chest Pain
 Physical Examination
General Fatigue. Compos mentis (GCS 456)
appearance BMI : obese
Blood Pressure 130/90 mmHg

Heart Rate 81 bpm

Respiratory Rate 20 x/mins

Temp 36,50C
 Physical Examination
Head Anemia (-); Icterus (-); Cyanosis (-); Dyspneu (-)
Neck Lymph nodes are not palpable, no JVD

Thorax Cor

Inspection : Ictus cordis not seen

Palpation : Ictus palpable at ICS V midclavicular line sinistra

Percussion :
- Right border : ICS IV parasternal line dextra
- Left border : ICS VI axillaris line anterior sinistra
- Heart waist : ICS II parasternal line sinistra

Auscultation : Regular S1 S2 heart sounds. No murmur and gallop heard.

 Physical Examination

Thorax Pulmo

I : Symetric movement in static and dynamic state

Pa: Vocal tactile fremitus symmetrical at both side
Pe: Sonor on all lung field
A: Vesicular breath sounds. Ro (-) Wh (-)
 Physical Examination
Abdomen I : Scar (-), jaundice (-)
A : Bowel sound (+) normal
Pe : Tympany in all regio, shifting dullness (-)
Pa : Soft, Tenderness (-)

Extremities Warm acral, edema (-/-)

 Lab Value
(19/11/2018) Lab Value

Hemoglobin 15,2 12 – 16 Total 217 <200

Cholesterol
Leukosit 8,3 4,7 – 11,3
Triglycerides 238 <150
Trombosit 190 150 – 450 ribu/ul
BUN 20,4 10-50
Hematokrit 45 38 – 42 %
Creatinin 0,9 0,6-1,1
Eritrosit 5,1 4 – 5 juta/ul
GDS 67 <140
MCV 88 80 – 93
Na 137,2 136-145
MCH 29 27 – 31
K 3,99 3,5-5,1
MCHC 33 32-36
Cl 104,4 97-111
Hitung jenis leukosit
Eosinofil (%) - 0-3
Basofil (%) - 0-1
Neutrofil (%) 72 50-62
Limfosit (%) 26,6 25-40
 EKG

ST elevations in
all leads
Thorax X-Ray (PA)

Cardiomegaly
 Initial Diagnosis (Causes and Diagnosis Therapeutic
Cue & Clue Problem List Monitoring
Etiology) Planning Planning

Male, age 45

• Chest pain 1. Stable 1. Acute coronary 1. EKG Non- 1. Vital sign

more than 10 Angina syndrome pharmacological
minutes Pectoris 2. Thorax X- treatment : 2. Urine
• Risk factor :
2. Myocard infarct Ray (PA 1. Low fat diet production
fatty diet –
position)
sedentary
lifestyle Pharmacological
treatment :
Physical Exam 1. Inf. PZ lifeline
• BP :130/90 2. Inj. Furosemide
• HR : 81 bpm 2x1 amp IV
• H/N : PO :
A/I/C/D : +/-/-/- 1. Fasorbid 2x5 mg
• Auscultation : 2. Spironolactone
Rh +/+ 50 mg 1x1
• Warm acral 3. Valisanbe 2 mg
2x1
Lab data 4. Forgoxin 1x1
• Total
cholesterol :
217
• Triglycerides :
Any discussion ?