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    Duty Report: Wednesday, June 14 2017

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    Qonita Aizati Qomaruddin
    1. Mrs. R presented with sudden chest pain and a history of hypertension. 2. Her examination found elevated blood pressure and continued chest pain. 3. She was assessed with unstable angina and hypertension, and treated with nitroglycerin and monitoring of vital signs.

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    Duty Report: Wednesday, June 14 2017

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    Qonita Aizati Qomaruddin
    28 views29 pages
    1. Mrs. R presented with sudden chest pain and a history of hypertension. 2. Her examination found elevated blood pressure and continued chest pain. 3. She was assessed with unstable angina and hypertension, and treated with nitroglycerin and monitoring of vital signs.

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    Hipertensi

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    Lapjag HT

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    1. Mrs. R presented with sudden chest pain and a history of hypertension. 2. Her examination found elevated blood pressure and continued chest pain. 3. She was assessed with unstable angina and hypertension, and treated with nitroglycerin and monitoring of vital signs.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    28 views29 pages

    Duty Report: Wednesday, June 14 2017

    Uploaded by

    Qonita Aizati Qomaruddin
    1. Mrs. R presented with sudden chest pain and a history of hypertension. 2. Her examination found elevated blood pressure and continued chest pain. 3. She was assessed with unstable angina and hypertension, and treated with nitroglycerin and monitoring of vital signs.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 29

    DUTY REPORT

    Wednesday, June 14th 2017


    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(-)
    Physical Examination
    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 (-)
    Physical Examination
    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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