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POMR ICVCU ROOM tugas

The document details the medical case of Mr. Nur Cholis, a 45-year-old male presenting with chest pain and a history of uncontrolled diabetes and controlled hypertension. Physical examination and ECG results indicate sinus tachycardia and signs of ST elevation myocardial infarction (STEMI) in the anterolateral leads. Laboratory tests reveal elevated glucose and lipid levels, and a treatment plan including various medications and interventions is outlined.

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11 views19 pages

POMR ICVCU ROOM tugas

The document details the medical case of Mr. Nur Cholis, a 45-year-old male presenting with chest pain and a history of uncontrolled diabetes and controlled hypertension. Physical examination and ECG results indicate sinus tachycardia and signs of ST elevation myocardial infarction (STEMI) in the anterolateral leads. Laboratory tests reveal elevated glucose and lipid levels, and a treatment plan including various medications and interventions is outlined.

Uploaded by

alwi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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POMR

ICVCU ROOM
SMF JANTUNG
Kelompok J10
FK UWKS - RSKK
6 JANUARI
7 JANUARI 2025
2025
POMR

Bed 8
PATIENT IDENTITY
Name: Mr. Nur Cholis
Age: 45 years old
Date of birth : 25 December 1979
Address : Keling, Kediri
Gender: Male
ANAMNESIS
Main complain : Chest pain
History Of Current Disease: The patient came with complaints of left chest pain since
09.30 AM, the pain felt like being pressured on a heavy things, the pain radiated to all of the
chest. The pain was suddenly came out of nowhere and was felt like more than 20 minutes
and the patient felt this symptom after do some small activity. The patient also came with
cold sweat. This is the first time a patient has experienced symptoms like this. No
complaints about shortness breath, no complaints about nausea or vomiting.
ANAMNESIS
Post History of Disease :
DM (+) not controlled, HT (+) controlled

Family History Of Disease :


DM (-), HT (-), history of heart disease (-)

Medication History :
Patient didn’t consume any medication before go to hospital

Social History :
The patient is food vendor

Allergic History :
The patient stated that they do not have a history of allergies to food and medications
PHYSICAL EXAMINATION
Vital Sign at ER:
General condition : weakness, compos mentis General condition : weakness, compos mentis
GCS : 4-5-6 GCS : 4-5-6
Vital Sign : Vital Sign :
Blood pressure : 148/80 mmHg Blood pressure : 196/126 mmHg
Heart rate : 92 x/minute Heart rate : 130 x/minute
Respiration rate : 20 x/minute Respiration rate : 22 x/minute
Temperature : 36,2 C Temperature : 36,3 C
SpO2 : 97% dengan O2 nasal cannul 3 lpm SpO2 : 97% dengan O2 nasal cannul 3 lpm
Random Blood Glucose : 236 mg/dl Random Blood Glucose : 250 mg/dL
PHYSICAL EXAMINATION
Head :
A/I/C/D : -/-/-/+
Neck :
Lymph notes : no enlargement of lymph nodes
JVP : increased (-)
Thorax :
Cor:
- Inspection : IC not visible
- Palpation : IC palpable at ICS V midclavicula line
- Percussion : Dullness at the heart border
- Auscultation: S1-S2 regular, gallop (+), murmur (-)
PHYSICAL EXAMINATION
Thorax :
Pulmo:
- Inspection : symmetrical (n/n)
- Palpation : fremitus (+/+)
- Percussion : resonance (+/+), dull (-/-)
- Auscultation : rhonchi (-/-), wheezing (-/-), vesiculer (+/+)
Abdomen :
- Inspection : distended abdomen (-), lesions (-)
- Palpation : bowel sound (+) normal
- Percussion : tenderness (-)
- Auscultation : tympani in the abdominal region (+)
Extremity :
- warm extremities (+/+/+/+)
- CRT < 2", edema (-/-/-/-)
ECG AT ER RSKK
1. Ritme (Rhytm) : Sinus Tachycardia with blocked
premature atrial complexes
2. Heart Rate (HR): 90 bpm reguler
3. Axis : Normal axis
4. Conduction (Konduksi) : P wave 100 ms, PR
Interval 150 ms. QRS Duration: 86 ms (normal).
QT/QTc: 350/429 ms (QT normal/QTc normal).
5. Chamber ventricular enlargement : RVH (-), LVH
(-)
6. Chamber artrial enlargement : RAE (-), LAE (-)
7. ST Elevasi V5, V6, Lead I, avL

Conclusion : Sinus tachycardia with PAC(s), heart


rate 90 bpm regular, STEMI Anterolateralis
SUPPORTING
EXAMINATION Laboratory Examination

Hasil Rujukan

Leukosit 13,3 4.3 - 11.3 10^3/ uL

Hemoglobin 16,3 12.5-16 gr/ dL

Hematokrit 46,2 35-45

Trombosit 346 150 - 400 10³/uL

SGOT 16,1 <31 U/L

SGPT 28,8 <32 U/L


SUPPORTING
EXAMINATION
Laboratory Examination

Hasil Rujukan

Ureum 19 10-50 mg/dL

BUN 9 4-20 mg/dL

Creatinin 0,87 0,5-1,1 mg/dL


SUPPORTING
EXAMINATION
Laboratory Examination

Kimia Klinik Hasil Rujukan

Kolesterol 197 <200 mg/dL

Trigliserida 241 <150 mg/dL

HDL 35 >45 mg/dL

LDL 114 <130 mg/dL

Natrium 140 135 - 145 mmol/L


SUPPORTING
EXAMINATION
Laboratory Examination

Kimia Klinik Hasil Rujukan

Kalium 4,4 3,5 -5,5 mmol/L

Asam Urat 4,5 2,4 -5,7 mg/dl


SUPPORTING
EXAMINATION

Heart Marker Hasil Rujukan

Troponin I <0,1 <0,3 ng/mL

CK-MB 5,1 0-5 ng/mL

HbA1c 10,4 4,5-5,9%


PTx:
Inf. PZ 1000 cc/ 24 jam
Sp. NTG 30 mcg/menit
Inj Lansoprazole 1x 30
Inj Furosemide 2x1
Inj Amiodarone bolus 150
Sp. Amiodarone 1 mg/ hari 6 jam
Sp. Amiodarone 0,5 mg/hari 18 jam
PO loading Clopidogrel 4 tablet
PO loading Aspilet 4 tab
PO Spironolakton 25-0-0
PO Candesartan 0-10-0
PO Bisoprolol 0-0-25
PO Aspilet 80-0-0
PO Briclot 2x90
PO Lovastatin 0-0-40
PO Alprazolam 0-0-0,5
TERIMA KASIH

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