Duty Report: Co-Assistant On Duty: Fadhila Ayu Safirina Succi Islami Putri

DUTY REPORT
Wednesday, June 14th 2017
Co-Assistant on duty:
Fadhila Ayu Safirina
Succi Islami Putri
Identity
Name: Mrs. R
Age: 75 years old
Address: Johar Baru, Jakarta Pusat
Occupation: Housewive
Marital Status: Married
Anamnesis
Chief Complain
Chest pain 3 hours prior entering hospital
History of Present Illness
Patient came with chest pain that had been felt 3
hours prior entering the hospital. The patient
described the pain as if her chest was punched.
The pain didnt relieved with rest and worsen
with stress. It was the first time she felt this chest
pain and it came suddenly. Shortness of breath,
heartburn, nausea, and vomiting was denied
upon anamnesis.
The patient presented with high blood pressure.
The patient had been diagnosed with
Hypertension for the last 10+ years.
History of Past Illness
Hypertension, controlled, 10+ years
Diabetes Mellitus, uncontrolled, 3 years
History of any allergies was denied.
History of any other disease was denied.
History of Medication
Amlodipin 1 x 8mg
Candesartan 1 x 10mg
Clinical Examination
General Status and Vital Sign
General Status: Mildly ill
Consciousness: Composmentis
Vital sign
BP: 179/80 mmHg
RR: 20 x
Temperature: 36.5C
Pulse: 72 x
Physical Examination
Head: Normocephal
Eyes: Anemic Conjunctiva (-/-), Icteric Sclera (-/-)
Mouth: cyanosis (-), typhoid tongue (-)
Nose: secrete (-/-), bleeding (-/-), septum
deviation (-/-)
Ear: secrete (-/-)
Throat: uvula in the middle, hyperemic (-), T1/T1
Neck: lymph nodes enlargement(-)
Pulmonary:
I: Normochest, symmetric, intercostal retraction (-)
P: Symmetrical tactile fremitus
P: Resonant all over lungs.
A: Vesicular (+/+), Rales (-/-), Wheezing (-/-)
Cardiac
I: Ictus Cordis not visible
P: Ictus Cordis palpated at linea mid clavicula sinistrae
ICS IV
P: All heart borders are normal
A: S1 and S2 normal, regular, murmur (-), gallop (-)
Abdomen:
I: flat
A: bowel sounds (+),
P: tympanic all over abdomen, shifting dullness (-)
P: no pain detected
Extremities
Warm upper and lower extremities
Edema on lower extremities (-/-)
Cyanosis (-)
Pitting oedema (-)
Laboratory Result
Hb: 11.3 gr/dL*
Ht: 34 %*
RBC: 4.0 mil/L*
WBC: 6970/L
Thrombocyte: 138.000 /nL*
MCV: 85 fL
MCH: 28 pg
MCHC: 33 gr/dL
Laboratory Result
Na: 144 mmol/ L
Kalium: 5.1 mmol/L
Chloride: 106 mmol/ L
Troponin: <0.01 ng/mL
CPK: 81 U/L
CK-MB: 14 U/L
Resume
Mrs. R, 75 years old, came with chest pain that was
described like a punch on the chest 3 hours prior
entering the hospital. The pain came suddenly, didnt
relieved with stress, and worsen with stress. The
patient admitted she has Hypertension for already
more than 10 years.
From physical examination: blood pressure
179/80mmhg, RR 20x/minute, heart rate 72x/minute,
and temperature 36.5. All heart borders are normal,
and patient complained a continued chest pain. Lab
result didnt indicate any sign of infarc myocard, but
showed an increased blood glucose.
Problem List and Assessment
Problems List
Unstable Angina
Hypertension grade II
Assessment
1. Unstable Angina
Anamnesis: sudden chest pain described as
punched pain, not relieved with rest
Treatment: ISDN 5mg, Injeksi Ketorolac
Monitoring: vital sign, clinical symptoms
Assessment
2. Hypertension grade II
Anamnesis: high blood pressure upon
examination, history of hypertension (10+ years)
Physical Exam: increased blood pressure (BP
179/80 mmHg)
Treatment: ISDN 5mg
Monitoring: vital sign
Angina Pectoris Classification
Stable Angina
Happened in the middle of activity
Every episode lasts no more than 5 minutes and
predictable
Relieved with rest or with medication
Sometimes the pain spread to shoulder, other chest
area, or back
Unstable Angina
Can occurred at rest, sometimes at nighttime
Pain episodes are unpredictable and can last up to
30 minutes
Cannot be relieved with rest or painkiller medication
A significant sign of an AMI
Pharmacological Treatment
Acute episode treatment:
Nitroglyceryin sublingual. Can be repeated after 3-5 minutes
Maintenance treatment
Long-acting: ISDN 3 x 10-40 mg oral.
Beta-blocker : Propanolol, Metoprolol, atenolol, pindolol.
CCB: verapamil, diltiazem, nifedin, nikardipin, isradipin.
Invasive treatment: PTCA (Percutaneus Transluminal Coronary

Angioplasty) and CABG
Life style alteration

Hypertension Classification
Sumber: American Society of Hypertension and the International Society

of Hypertension, 2013
Diagnosis
Treatment
Prognosis
Quo ad vitam: dubia
Quo ad functionam: dubia ad bonam
Quo ad sanationam: dubia ad malam

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DUTY REPORT

Wednesday, June 14th 2017

Invasive treatment: PTCA (Percutaneus Transluminal Coronary

Life style alteration

Sumber: American Society of Hypertension and the International Society

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