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GRAND ROUNDSeptember 10th2015
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NO NAME AGE DIAGNOSIS1 Mr. Sp 57 CHF NYHA III ec CAD 3VD + on PPM +
Ascites + DM
Mr. !" 5# $AP %I&&IP I 'IMI ()7 CAD 3VD + H'st*e II + DM tipe II + post PCI ,sept-15
3 Mr. M #- CHF NYHA III/IV ec se0ere M!'!PH +A 2 NV! + H4pertiroi
( Mr. 'D #- ADHF p** CHF NYHA II ec OMI*nterosept*6 + H' + 4s6ipiei*
5 Mr. PD 7
CC I December 2015
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NO NAME AGE DIAGNOSIS
1 Mrs. S #5 S'EMI in8erior
Mrs. S6 5( CHF ec HHD
3 Mrs. SS 59 CHF ec HHD M! AF
( Mrs. S! #- Pro PAC st*n4 PCI
FEMALE WARD September 3rd 2015
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NO NAME AGE DIAGNOSIS
-1 1 Mr. % (# CHF NYHA II ec A! se0ere
Possi6e IE
Mr. N # S'EMI in8eroposterior
- 1 Mr. S # CHF NYHA III ec s:sp IHD DMe8:si p6e:r* :p6e;
CHF ec IHD pro PCI
-3 1 Mr. S" 5# APS CCS II/III pro PCI
#5 CHF recent S'EMI *nterior
-( 1 Mrs. S < CHF NYHA III ec HHD AFs:c6inic*6 H4pertiroi
Mrs. N 5# CHF ec DCM 4s6ipiei*
-5 1 Mr. Sn #5 NS'EMI =i66ip I
Mr. > (( S'EMI e;tensi0e *nterior?istor4 o8 A&O post PCI
CC I J!e 1"th 2015
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Diagnosis
NSTEMI
CHF NYHA II ec IHD
PCI history in March 2015 Hypertension st II
Dysipi!e"ia
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C#$e %&$tr#t%'!
Patient identity
Na"e # Mr S
A$e # %% yo
A!ress # &esani 'T ()'* 1
+cc,pation # 'etire!
Date o- a!"ission # Septe".er /th 2015
Ins,rance # &PS non P&I
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Recent history
Chief complaint : chest pain
At 'SD
Chest pain 34 Patient too6
another ISDN s,.in$,ay Pain
!ecrease! a itte in intensity
Dyspnea 748 Papitation 748
syncope 74
9 ho,rs .e-ore a!"ission
Chest pain 348 -et i6e hea:y press,re8 ra!iatin$ to nec6 an
e-t ar"8 90 "in,tes !,ration8 !i! not reie:e ;ith rest Na,sea
348 Diaphoresis 348
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!IS% FAC'O!S FO! CAD
()perte!$%'!
*+,
DM *-,
D)$&%p%dem%#
*+,
Sm'.er *-,
F#m%&)
h%$t'r)
*-,PAS' MEDICA& HIS'O!Y
G*stritis /
Ast?* /
A66er4 /
Stro=e /
%ine4 ise*se /
A6co?o6 *:se /
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Meic*tion ?istor4
Mini*spi 9-)(?o:r
F:roseie (-)(?o:r
Di6ti*e 3-)1?o:r C6opis*n 75)(?o:r
Si0*st*tin 1-)(?o:r
Ison*t 1-)(?o:r Spirono6*ctone 5)(?o:r
Dio0*n 9-)(?o:r
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F*i64 Histor4
H4pertension ,+
'?ere is no 8*i64 eer "it??istor4 o8 ?e*rt ise*se
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PHYSICA> E?AMINATI+N
Ge!er#& C'!d%t%'! #!d /%t#&
S%!$&e0e6 o8conscio:sness
Coposentis
GCS E(V5M#
Gener*6conition Moer*te64 i66
Bei?t #- =
Hei?t 1#5 c
@MI -3 =)
@P 1#-)1-- HH!
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PHYSICA> E?AMINATI+NChe$t
HEA!'Inspection IC c*n e seen on 5t? ICS
c 6*ter*6 to &MCSP*6p*tion IC "*s p*6p*te on 5t?ICS
c 6*ter*6 to &MCS
A:sc:6t*tion Nor*6 S1 S M:r:r ,/ G*66op ,/
&$NGInspection S4etric "?i6e in st*tic
4n*ic st*teP*6p*tion E:*6 ste 8reit:s in ot?
6:n 2e6sPerc:ssion SonorA:sc:6t*tion Vesic:6*r +)+ !*6es +)+ ini*6 *t 6:ns
*se Cr*c=6es /)/ B?eein /)/
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Abd'me!
Inspection F6*tA:sc:6t*tion Nor*6Perc:ssion D:66 in ri?t :pper :*r*nt s?i8tin :66nes ,/P*6p*tion &i0er c*n e p*6p*te c e6o" *rc:s cost*e
Etrem%t%e$
B*r e;treities Ee* /)/ C4*notic /)/ G*strocnee:s p*in /)/ C6:in 2ner /)/
PHYSICA> E?AMINATI+N
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DIAGNOS'IC S'$DIES
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ECG ,Septeer 9t?-15 -7.--
Sin:s r?4t?. #-;)enit. &AD. &AF@. &AE. p*to6ois i V1/V5
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&*or*tori:
PEME!I%SAAN HASI& SA'$AN NI&AI NO!MA&
HEMA'O&OGI ,7)< -15
H 133 )& 1-- J 15--
Hct 37 K 35 J (7
Eri (11 1-#)L& (( J 5