Page 37 - FCN

b. Analyze the patient’s chart and handover the patient to the next shift by communicating the

condition using ISBAR.

Lastri Wiyono

Female/ 64 years DOB : Oct/10/1959
Dept : Cardiology IN : Aug/09/2023
Ward : 3 OUT : n/a

Current symptoms: Health issues & medication
1. Chest pain is intense in 10 minutes Dyspnea for the last two weeks
duration and subsides after taking
nitroglycerine. Under medication for:
2. Normal, pale skin, decreased skin turgor. 1. Arterial hypertension (the last 10 years)
2. Diabetes mellitus type 2 (the last 7 years)
Interpretation: Request:
1. Auscultation of heart: regular without 1. Biochemical blood test
pathology, accentuation of the second 2. Urine test
heart sound near the aorta. 3. ECG
2. Heart rate: 84 bpm, pulse 84 bpm. 4. Blood test for Troponin.
3. May indicate Ischemic heart disease –
Angina pectoris.

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