MORNING REPORTTuesday, 4th March 2014Wahidin Sudirohusodo HospitalSheila WitjaksonoTitus KurniaHarie CiptaDian PratiwiSitti Multa Zam

Patient identityName : Mr. HNAge : 60 years oldAddress : Tamangappa Raya No. 325MR: 624107Date of Admission : March 1st,2014

History TakingA 60 y/o man, was referred from Ibnu Sina Hospital with NSTEMIChief complaint of shortness of breathSOB (+) since a week ago worsen since last night, DOE (+), PND (+), orthopnea (+), cough (+) with white mucousEpigastric pain (+) since last night (+ 20 hours before), with burning sensation accompanied by naussea with no vomiting. History of chest pain since 3 days ago, pressed-like sensation with duration less than 10 minutes, not radiated to back nor upper limb, triggered by activity and relieved by rest and ISDN SL. He had hospitalized last year and had accepted 5 days of fondaparinux sub cutaneus injection. History of angiography with Non significant LCX stenosis (on august 2013). In the last 3 months, he was not taking regular medication.Cough (-), febris (-).Micturation and defecation remains normal as usual. History of black colouring stool (+) last year.

History of HT (+), not taking regular treatment, DM (-)History of smoking (+) for >20 years, and had stopped on day before admitted to the hospitalHistory of routine herbal consumption (dragon fruit) since last year.History of blood transfusion (+) >4 bag last year.History of blunt abdominal trauma a month ago.

Physical ExaminationGeneral status: mod-ill/well-nourished/consciousBP: 160/90 mmHg, P : 92 bpm (reguler), RR : 28tpm, T : 36,5 CConjunctiva anemic (+/+), icterus (-)JVP R+3 cmH2O (30)Vesicular breath sound, ronkhi (+) at mediobasal both of lungS 1/2 reguler, no murmur Peristaltic (+), soepel (+), with tenderness on the all abdominal region, especially on the epigastric region.Hepar palpated 3 cm below arcus costa, unpalpated spleenLower extremity oedema (+/+) on the dorsum pedis, warm acralRT : Nipping sphincter, smooth mucosa, no palpable mass, Handscoen : feces (+) with yellowish colouring, no blood nor mucus.

ECG @ Ibnu Sina HospitalSinus rhythm , HR 95 x/minute, axis -20, P wave 0,08s, PR interval 0,16 s, QRS complex 0,08 s, ST depression V4-V6 T-inverted I,aVL,V5-V6.RV5+SV2 = 39.Conclusion: Sinus rhythm, normoaxis, Anterolateral ischemia,, LVH (+)

Sinus rhythm , HR 95 x/minute, axis -20, P wave 0,08s, PR interval 0,16 s, QRS complex 0,08 s, ST depression V5-V6 T-inverted I,aVL,V5-V6.RV5+SV2 = 39.Conclusion: Sinus rhythm, normoaxis, Anterolateral ischemia, LVH (+).

ECGECG @ ER

CHEST X-RAY

Cardiomegaly, CTI 0,6Normal cardiac waistSign of pulmonary oedema (-)

Normal bronchovascular markingNo specific process on the both of lungCardiomegaly, CTI 0.62 with dilatation and elongation of aortaNormal sinus and diaphragmaIntact bone

Conclusion:Cardiomegaly with dilatatio et elongatio aortae.Atherosclerosis aortae.

3 position of BNOAir on the instestine distributed through distal.Intestinal loop not dilated, no herring bone appearance.No sub diaphragm free air.Intact both psoas line and peritoneal fat line.Intact bone

Conclusion:No sign of peritonitis at the time x-ray taken.

Lab. FindingsWBC : 13.5 x 103 /uLHB : 4.9 mg/dLMCV: 70 m3MCH: 20 pgMCHC : 27 g/dlHCT : 18.5%PLT: 547x 103 /uLRBC : 3.45x 106 /uLUr : 36 mg/dLCr: 1.20 mg/dLGOT: 11 mg/dLGPT: 9 mg/dLTrop. T: Negatif

AssesmentCHF NYHA III ec HHDEpigastric pain syndrome ec suspecy drug gastropathyCADAnemia mikrositik hipokrom ec ?

ManagementO2 3-4 Lpm via nasal canuleIVFD NS 500 cc/24 hrsInj. Furosemide 40 mg/12 hours/IVCaptopril 3x12.5 mgISDN 5 mg SLTransfussion of PRC 3 bag, 1 bag/dayInj. Omeprazole 1 vial/ 12 hours/IV Sucralfat syr 3x2 C

PlanBlood smear analysis before transfussionUSG AbdomenEchocardiography

Patient identityName : Mrs. HAge : 61 years oldAddress : Jl. Bonelengga Caddika No. 12 MakassarMR: 653047Date of Admission : March 1st,2014

History TakingPatient was consulted from internal Department with ACS, unconscious woman 61 years. She was referred from RSUD Daya. She has been unresponded since she was transported to the hospital. At the time she arrived to RSUD Daya she was complained the chest pain she felt since 12 hours before, pressed like sensation, radiated to the back and the jaw, accompanied by cold sweat and shortness of breath. Her family denied the history of chest pain before. History of HT (+), DM (+), not taking regular medication.History of smoking (-).

Physical ExaminationGeneral status: sev-ill/poor-nourished/unconscious ( GCS E1M1V1)BP: undetectable, P : unpalpated, RR : (-)Carotid artery : unpalpableConjunctiva anemic (-/-), icterus (-)S 1/2 (-) Extremity oedema (-/-), cold acralECG on monitor : Bradikardi HR 47

ECG

AssesmentPulseless Electrical Activity

ManagementCardiopulmonary Resuscitation CPR through 30 minutes, no response Pupil total midriatic, no light nor corneal reflex The patient died at 22.45 pm.