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    Morning Report Monday, April 30Th 2011: Physician in Charge: Ia: DR Ames, DR Sigit Ib: DR Hidayat, Drheri Ii: DR Riza

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    Juwita Valen Ramadhannia
    1. Mrs. M is a 72-year-old female admitted for shortness of breath. She has a history of hypertension. 2. Physical exam found an irregular heart rate of 25 bpm and ECG showed complete heart block. Laboratory tests showed electrolyte abnormalities. 3. The patient is diagnosed with complete heart block and congestive heart failure. Treatment plans include temporary pacing, diuretics, and preparing for permanent pacemaker placement.

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    Morning Report Monday, April 30Th 2011: Physician in Charge: Ia: DR Ames, DR Sigit Ib: DR Hidayat, Drheri Ii: DR Riza

    Uploaded by

    Juwita Valen Ramadhannia
    11 views9 pages
    1. Mrs. M is a 72-year-old female admitted for shortness of breath. She has a history of hypertension. 2. Physical exam found an irregular heart rate of 25 bpm and ECG showed complete heart block. Laboratory tests showed electrolyte abnormalities. 3. The patient is diagnosed with complete heart block and congestive heart failure. Treatment plans include temporary pacing, diuretics, and preparing for permanent pacemaker placement.

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    1. Mrs. M is a 72-year-old female admitted for shortness of breath. She has a history of hypertension. 2. Physical exam found an irregular heart rate of 25 bpm and ECG showed complete heart block. Laboratory tests showed electrolyte abnormalities. 3. The patient is diagnosed with complete heart block and congestive heart failure. Treatment plans include temporary pacing, diuretics, and preparing for permanent pacemaker placement.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    11 views9 pages

    Morning Report Monday, April 30Th 2011: Physician in Charge: Ia: DR Ames, DR Sigit Ib: DR Hidayat, Drheri Ii: DR Riza

    Uploaded by

    Juwita Valen Ramadhannia
    1. Mrs. M is a 72-year-old female admitted for shortness of breath. She has a history of hypertension. 2. Physical exam found an irregular heart rate of 25 bpm and ECG showed complete heart block. Laboratory tests showed electrolyte abnormalities. 3. The patient is diagnosed with complete heart block and congestive heart failure. Treatment plans include temporary pacing, diuretics, and preparing for permanent pacemaker placement.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 9

    Morning Report

    Monday, April 30th 2011

    Physician in Charge:
    IA: dr Ames, dr Sigit
    IB: dr Hidayat, drHeri
    II : dr Riza
    Summary of Data Base
    Mrs. M/72 y.o
    Chief complaint: Shortness of breath (SOB)
    Patient suffering from SOB since 1 weeks before admission
    gradually onset worsening since 3 days before admission
    History had treatment by GP with 6 kind of drugs but didn’t any
    improvement then admission in Budi Rahayu hospital for1 days
    and got treatment levemir 0-18 iu sc, actrapid 8-8-8 iu sc,
    Atropine 6x 1 ampul and nifedipine 3x5mg
    History blood glucose was 306 when admitted in Budi Rahayu
    Hospitals
    History blood pressure was 180/… since 2 years ago didn’t
    routinely controlled
    ER 2-4-2011 (11.30 pm)
    BP : 140/75
    PR :25
    RR :20

    Treatment:
    Dopamin drip 5-15 mikro/mnt
    Physical Examination
    General appearance: looked severe ill, GCS: 456,
    BP: 130/750 mmHg ; HR: 25 bpm, reguler; RR : 20 x/mnt;
     Head & Neck: an (-), ict (-), JVP R+2cm H20
     Thorax :
     Heart : ictus invisible, palpable at ICS VI cm lateral MCL S + 1cm lateral

    LHM ~ ictus, RHM at SL D


    S1, S2 single, murmur (-)
     Lung : Simetris, S S V V Rh - - Wh - -
    S S V V - - - -
    S S V V - - - -
     Abdomen: flat, soefl, BS (+) N, met (-)
    Liver: palpable, liver span 10 cm,
    Spleen: unpalpable, troube space tympani
     Extremity: edema -;
    ECG Result 03/04/2011
    at 02.25 PM
    Arrytmia HR :
    Atrial rate :100 tpm
    Ventrikular Rate : 25 tpm
    FA : LAD
    HA : CCW
    PR interval : difficult to evaluate
    QRS complex : 0,10”
    QT interval : 0,28”
    Dissosiation p and qrs wave
    Conclusion: AV block 3th degree
    LABORATORY FINDING
    Lab,august, Value Lab Value

    Leukocyte 9.800 3500-10000/µL SGOT 12 11-41 U/L


    Haemoglobin 13.4 11,0-16,5g/dl SGPT 45 10-41 U/L
    Trombocyte 180.000 150000-390000/µL Albumin 4.41 3.5-5.5 g/dl

    Hematocrite 29,6
    RBS 146 Limfosit 3100
    Ureum 54.2 Na 130 136-145 mmol/L

    Creatinine 1,00 0,7-1,5mg/dL K 3,4 3.5-5.0 mmol/L

    CPK 156 30-190 U/L Cl 110 98-106 mmol/L


    32
    CKMB <25 U/L:

    Troponin I (-) 0,1 - ng/ml


    Blood Gas Analysis
     Temperature : 37,5 C
     pH : 7,401
     pCO2 : 30,4
     pO2 : 98,2
     HCO3 : 20,5
     O2 saturation : 97,4
     Base Excess : - 6,0
    CUE AND CLUE PROBLEM INITIAL PLANNING PLANNING THERAPY P mon
    LIST DIAGNO DIAGNOSE
    SE

    female, 72 y.o 1. Total  O2 NC 4 lpm ECG


     Semifowler position
    SOB AV
     IVFD NS 0.9% lifeline
    HR 25 tpm Block
     Fluid Balance (-)
    ECG AV block  SA 0.5 mg iv
    total  Allupent 2x1 tab
     Dopamin5-15
    Cardiomegaly
    micro/KGBW/Mnt
    Prepare Permanent Pace maker

    Female 72 y.o 2 HF str C Echocardiog . ISDN 3x5 mg


    raphy
    PND fc III .Nifedipine 3x5mg
    Dispneu
    d’effoet
    History of
    hipertension
    Cardiomegali
    CUE AND CLUE PROBLEM INITIAL PLANNING PLANNING THERAPY P mon
    LIST DIAGNO DIAGNOSE
    SE

    female, 28 y.o 3. DM type  DM diet 1700 kcal/hr VS,


     Insulin rapid acting 8-8-8
    History BG 2 cardiac
    iusc enzym
    304dl  Insulin Long acting 0-18
    ECG
    Treatment By
    insulin

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