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    Dhian Hidayat
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    1. The morning meeting discussed a 52-year-old male patient, Tn. YS, who presented with chest pain and was diagnosed with an ST-elevation myocardial infarction (STEMI). His vital signs and physical exam findings were reported. 2. The initial treatment plan involved medications like aspirin, clopidogrel, isosorbide dinitrate, atorvastatin, and enoxaparin. His condition did not improve after 30 minutes to 1 hour so a plan for alteplase was discussed, with enoxaparin to be given 6 hours later. 3. His laboratory results including hemoglobin, leukocytes, platelets, renal and liver function,

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    1. The morning meeting discussed a 52-year-old male patient, Tn. YS, who presented with chest pain and was diagnosed with an ST-elevation myocardial infarction (STEMI). His vital signs and physical exam findings were reported. 2. The initial treatment plan involved medications like aspirin, clopidogrel, isosorbide dinitrate, atorvastatin, and enoxaparin. His condition did not improve after 30 minutes to 1 hour so a plan for alteplase was discussed, with enoxaparin to be given 6 hours later. 3. His laboratory results including hemoglobin, leukocytes, platelets, renal and liver function,

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    36 views5 pages

    Morning Report

    Uploaded by

    Dhian Hidayat
    1. The morning meeting discussed a 52-year-old male patient, Tn. YS, who presented with chest pain and was diagnosed with an ST-elevation myocardial infarction (STEMI). His vital signs and physical exam findings were reported. 2. The initial treatment plan involved medications like aspirin, clopidogrel, isosorbide dinitrate, atorvastatin, and enoxaparin. His condition did not improve after 30 minutes to 1 hour so a plan for alteplase was discussed, with enoxaparin to be given 6 hours later. 3. His laboratory results including hemoglobin, leukocytes, platelets, renal and liver function,

    Copyright:

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    of 5

    MORNING MEETING IGD

    Hari/Tanggal : Senin/15 Juli 2019


    Moderator : dr.
    Penyaji : dr. Helena Parisianne Irianto
    Waktu : 13.00 WITA
    Tempat : Ruang Komite Medik
    Senin, 15 Juli 2019
    dr. Rina / dr. Caesar
    N NAM Dx awal (H SUBJEKTIF OBJEKTIF DIAGNOSA THERAPY
    O A perawatan 05.10
    )
    1. Tn. YS Chest pain Keluhan Utama : Nyeri Vital Sign 05.15
    52 ec STEMI dada Kiri TD 240/140 Inj Ranitidin 1 amp
    tahun N 70 x/min Loading ASA 300 mg
    RPS
    T 37C Loading CPG 300 mg
    Nyeri dada kiri RR 20 x/min ISDN 75 mg SL
    menusuk, menjalar ke SpO2 98%
    lengan kiri, disertai mual BB 80kg 05.35
    & nyeri ulu hati GCS E4 V5 M6 Advis dr Suhardi Sp.JP
    Nyeri dirasakan sejak 2 Skala nyeri 3-4 Atorvastatin 1x40mg malam
    hari yll, memberat 1 ja Inj Arixtra 1x2,5 mg
    SMRS Kepala Leher ISDN 3x5 mg
    CA -/- SI -/-
    RPD : HT tidak 05.40
    terkontrol Thorax TD 240/140
    Pulmo : ves +/+ rho -/- Advis dr Suhardi Sp.JP
    whe -/- Perdipin 0,5 mEq syringe
    Cor : S1S2 reguler, pump, naikkan 0,5 mEq/30
    murmur - gallop – menit
    ISDN 0,5 mg/jam SP (tab stop)
    Abdomen Evaluasi 30 min – 1 jam, bila
    Supel, BU +, NT belum membaik rencanakan
    epigastrium + alteplase, bila alteplase masuk
    arixtra diberikan 6 jam setelah
    Ekstremitas alteplase
    Akral hangat, CRT < 2
    detik 05.50
    Melaporkan hasil PLT ke dr
    Suhardi Sp.JP
    Arixtra masuk

    DL Faal ginjal Faal hati Elektrolit


    Hb 16.4 Ur 22.5 SGOT 17.1 Na 139
    AL 11.14 Cr 1.1 SGPT 14.0 K 3.7
    PLT 127 Cl 105
    GDS 90

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