Morning Report

New Patient Mrs. M / 44 yo at ER Saiful Anwar Hospital (EM)

No SUBJECTIVE OBJECTIVES ASSESSMENT TREATMENT

1August 16th 2014 16.42

SOB Physic Diagnostic :BP 87/67 PR 120 bpm RR 26x/’ t 36.1ºCAirway: patent, clearBreathing: tachypneuCirculation: warm & dry acralBlood glucose:60

1. SOB dt ADHF2. Lung TB drop out

Bedrest, semifowler positionO2 10 lpm NRBM IVFD NS 0.9% life lineInj Ranitidin 50mg IVInj D40% 25 ml IVDrip NE start 0.05 mcg/kgBW/min

Dispose to Cardio

New Patient Mrs. M / 44 yo at ER Saiful Anwar Hospital

No SUBJECTIVE OBJECTIVES ASSESSMENT TREATMENT

118.15

Bloody coughBloody cough in th afternoon 3x. History of DOE (+) since 4 years ago intermittently when doing heavy activity. Orthopneu (+), PND (+), leg swelling (-), chest pain (-), palpitation (-). History of HTN (-) History of DM (-)History of hospitalization (-)History of controlled in Pulmonology and Internal outpatient clinic in Bangil hospital (+) but she didn’t know the name of the drugs.History of 6th months medication (-).She had 4 children and had normal labour.History of moving joint pain (-).History of decxrease appetite (+), history of decrease body weight (-).

Physic Diagnostic :BP 86/61 PR 145 bpm RR 26x/’ Sat O2 100% NRBMJVP R+ 2cm H2O(45)Rh - - Wh - - - - - - + + - -Ictus visible, palpable at ICS VII 1 cm lat MCL S, S1S2 N, M (?) sde, gallop (-)Abd flat, soefle, BS (+)N, liver span 8cmLeg edema -/-, cold acralThorax USG: -LA, RA, RV dilatation, Lvnormal- Doming AML

1. Shock 1.1 Cardiogenic 1.2 Non

cardiogenic2. Septic condition3. MSI 3.1 RHD

sequalae4. HF st C fc IV 4.1 MSI5. Hemoptoe dt ?6. Hyponatremia7.Hypoalbuminemi

a8. Azotemia9. Increase

transaminase

PDx:- Echocardiography- ECG serial, DL, UL, Ur, cr, SE, OT/PT, Albumin, lipid profile, UA - USG abdomen

PTx:Bedrest, semifowler positionO2 10 lpm NRBMTotal fluid intake 1500cc/24hIVFD NS 0.9% 500cc/hrFluid balance neg 500 cc/24hDrip NE 0.05-2mcg/kgBW/minDrip Dobutamin 3-15 mcg/kgBW/minInj Furosemide 40-0-0 mg Inj Ceftriaxon 2x1 g (skin test)Inj. Digoxin 1x0.25 mg IVPO:Spironolacton 0-25-0 mgN Acetyl Cystein 3x1 sachetLaxadin 0-0-C1Alprazolam 0-0-0.5 mgMove to CVCUECG (+)

CXR (+)

Lab (+)

ECG in ER (16/8/14, WIB)

CXR 29-6-2014

• AP position, asymetric, KV enough, enough inspiration• Trachea in the middle• Soft tissue thick and bone normal• Right are and left phrenico-costalis angle are sharp• Right and left hemidiaphragm are domeshaped• Lung: infiltrate in the medial of rightand sinistra lung• Cor: CTR: 65% cardiac, dilatation all chamber

Conclusion: cardiomegaly

Laboratory Finding at ER Lab value Normal

valueLab Value Normal

value

Leuco 16.700 3.500-10.000 Na

127 136-145

Hb 12.90 11-16.5 K 3.57 3,5-5

Thrombo 1427.000 150-390.103 Cl 106 98-105

PCV 36.80 35-50 Ureum 10-50

CPK 390 26-192 Creatinin 2.5 0,7-1.2

CKMB 38 7-25 Albumin 2.8 3,5-5,5

Trop I 0.2 <1 SGOT 1120 11-41

Uric acid 2.4-5.7 SGPT 694 10-41

Chol/TG/HDL/

LDL

- <200/<150/>50/<100 Neutrofil 77.1%

BLOOD GAS ANALISIS with NRBM 8 lpm

pH : 7. 34pCO2 : 23.4 mmHgpO2 : 104.3 mmHgHCO3 : 12.7 mmol/LO2 sat : 97.8 %BE : -13.3 mmol/L

Summary data base at CVCU• Chief Complain : Bloody cough• Bloody cough in th afternoon 3x. History of DOE (+) since 4 years

ago intermittently when doing heavy activity. Orthopneu (+), PND (+), leg swelling (-), chest pain (-), palpitation (-).

• History of HTN (-) • History of DM (-)• History of hospitalization (-)• History of controlled in Pulmonology and Internal outpatient clinic

in Bangil hospital (+) but she didn’t know the name of the drugs.• History of 6th months medication (-).

Summary data base at CVCU (cont’d)• She had 4 children and had normal labour.• History of moving joint pain (-).• History of decxrease appetite (+), history of decrease body weight

(-).

TIME LINE

4 years ago

SOB when doing heavy activity

1 day before admission

HF st C fc IV admitted

Worsening of SOB, bloody cough,

2 days

SOB worsened,cou

gh (+), whitthish sputum

HF st C fc IIIpneumoniaHF st C FC I-II

Physical Examination at WardGeneral appearance Looked moderately ill, CM

Looks normoweightBlood Pressure BP 100/80 Sat O2 100% (10lpm

NRBM)Pulse Rate 122 BpmRespiratory rate 24 tpmHead Anemic (- ), Icteric (-), Neck JVP + 2 cm H2O 450 positionThorax Heart

Ictus invisible palpable in ICS VII 1 cm lat MCL S RHM = SL D. LHM = ictusS1S2 N, m (+) systolic, gr II/VI, PM at apex radiated to axilla gallop (-), heaves -

Lung Symmetric v v Rh - - Wh - - v v - - - - v v + + - -

Abdomen Flat ,Soefl, met -, Bowel sound Normal, liver span 9cm, traube space tympani

Extremities Leg swelling +/+, warm acral

Urine production 50 cc

ECG in CVCU (17/08/14, 16.00WIB)

CUE & CLUE P. LIST I Dx P Dx P Th P Mo

Mrs. M / 44 yo- SOB- Orthopneu- Dyspneu d’ effort - PND- Not relieved by rest- Bloody choughPDx:-T: 100/80 mmHg; PR: 122x/m RR 284 tpm-Cardiomegaly, murmur (+)-Rh at all basal lung D&S- Oedem lower extremityECG: Sinus tachycardia HR 122 bpmCXR: Cardiomegaly, Lab: hiponatremia, hipoalbuminemia, increase transaminase

1. Post shock

1.1 Cardiogenic

1.2 Non cardiogenic

-Echocardiography- ECG serial, -- lipid profile, UA

PTx:Bedrest, semifowler positionO2 10 lpm NRBMIVFD NS 0.9% 500cc/hrDrip NE 0.05-2mcg/kgBW/minDrip Dobutamin 3-15 mcg/kgBW/minInj Furosemide 40-0-0 mg Inj Ceftriaxon 2x1 g (skin test)Inj. Digoxin 1x0.25 mg IVPO:Spironolacton 0-25-0 mgN Acetyl Cystein 3x1Laxadin 0-0-C1Alprazolam 0-0-0.5 mg

SubjectifBPPRRRUrine Production

CUE & CLUE P. LIST I Dx P Dx P Th P Mo

Mrs.M/ 44 yo- SOB- Orthopneu- Dyspneu d’ effort - PNDChough since 2 days, feverHistory of HTN >10 yearsPDx:-T: 100/80mmHg; PR: 122x/m RR 24 bpm-Cardiomegaly-Rh at all area lung D&S- Oedem lower extremityECG: Sinus tachycardia HR 122 bpmCXR: Cardiomegaly

2. Septic condition

Blood culture & sensitivity

Bedrest, semifowler positionO2 10 lpm NRBMIVFD NS 0.9% 500cc/hrDrip NE 0.05-2mcg/kgBW/minDrip Dobutamin 3-15 mcg/kgBW/minInj Furosemide 40-0-0 mg Inj Ceftriaxon 2x1 g (skin test)Inj. Digoxin 1x0.25 mg IVPO:Spironolacton 0-25-0 mgN Acetyl Cystein 3x1 sachetLaxadin 0-0-C1Alprazolam 0-0-0.5 mg

SubjectifBPPRRR

CUE & CLUE P. LIST I Dx P Dx P Th P Mo

Mrs. M/ 44 yo-SOB- Orthopneu- Dyspneu d’ effort - PND- Not relieved by rest- Bloody choughPDx:-T: 100/80 mmHg; PR: 122x/m RR 284 tpm-Cardiomegaly, murmur (+) systolic -Rh at all basal lung D&S- Oedem lower extremityECG: Sinus tachycardia HR 122 bpmCXR: Cardiomegaly,

3. MS

3.1 RHD sequalae

Echocardiography

Bedrest, semifowler positionO2 10 lpm NRBMIVFD NS 0.9% 500cc/hrDrip NE 0.05-2mcg/kgBW/minDrip Dobutamin 3-15 mcg/kgBW/minInj Furosemide 40-0-0 mg Inj Ceftriaxon 2x1 g (skin test)Inj. Digoxin 1x0.25 mg IVPO:Spironolacton 0-25-0 mgN Acetyl Cystein 3x1 sachetLaxadin 0-0-C1Alprazolam 0-0-0.5 mg

SubjectifBPPRRR

CUE & CLUE P. LIST I Dx P Dx P Th P Mo

Mrs. M / 44 yo-SOB- Orthopneu- Dyspneu d’ effort - PND- Not relieved by rest- Bloody choughPDx:-T: 100/80 mmHg; PR: 122x/m RR 284 tpm-Cardiomegaly, murmur (+) systolic-Rh at all basal lung D&S- Oedem lower extremityECG: Sinus tachycardia HR 122 bpmCXR: Cardiomegaly,

4. HF st C fc IV

4.1 MS eCHOCARDIOGRAPHY

Bedrest, semifowler positionO2 10 lpm NRBMTotal fluid intake 1500cc/24hIVFD NS 0.9% 500cc/hrFluid balance neg 500 cc/24hDrip NE 0.05-2mcg/kgBW/minDrip Dobutamin 3-15 mcg/kgBW/minInj Furosemide 40-0-0 mg Inj Ceftriaxon 2x1 g (skin test)Inj. Digoxin 1x0.25 mg IVPO:Spironolacton 0-25-0 mgN Acetyl Cystein 3x1 sachetLaxadin 0-0-C1Alprazolam 0-0-0.5 mg

SubjectifBPPRRRUrine Production

CUE & CLUE P. LIST I Dx P Dx P Th P Mo

Mrs. M / 44 yoBloody cough

5. Hemoptoe dt ?

Treat underlying disease Subj

Mrs. M / 44 yoNa: 127

6. Hyponatremia

Treat underlying disease SE/3 days

CUE & CLUE P. LIST I Dx P Dx P Th P Mo

Mrs. M / 44 yoAlb: 2.80

7.Hypoalbuminemia

Treat underlying disease SubjectifBPPRRR

Mrs. M / 44 yoCr: 2.5BUN 129

8. Azotemia Treat underlying disease Ur, Cr per 3 days

Mrs. M / 44 yoOT/PT: 1120/694

9. Increase transaminase

Treat underlying disease OT/PT per 3days

ECG in CVCU (18/8/14, 05.00 WIB)

This Morning 06.00

• Subjective : SOB decrease • BP :113/70• HR : 140 bpm• RR : 20 tpm• Urine : 60 cc/hr