Nov 23th ,2016

dr. Rudi Erwin

 Azwar, Male, 57yo, HCU-05

 Cc:

 Chest pain increased since 9 hours ago.

 Present Illness History

 Chest pain increased since 9 hours ago. Initially chest pain felt since 1
week ago. Intermittent. Duration > 20 minute. Do not decreased with rest
 Breathlessness increased since 1 day ago. Affected by activity, not affected
by food and weather. History of woke up in the midnight because of
brethlessness (+). History of sleeping with the elevated by pillows for
decreased of brethlessness (+).
 Swelling of the foot since 1 week ago
 No fever
 No cough
 No palpitation
 Micturation and defecation normal
 Patient referred from Semen padang hospital with the diagnozed NSTEMI
inferior
 
Past Illness History
• History of HT (-)
• History of DM (-)

Family Illness History

• Nothing family with the same of diasease
 Physical Examination

 Consciousness level : CMC

 BP : 120/80 mmHg

 HR : 57x/minute

 RR : 28x/minute

 T: 36,4 C
 Eye
 Conjunctiva are anemic -/-
 Sclera are icteric -/-

 Neck
 JVP 5+2 cmH20

 Lung:
 Inspection: simetric at statis and dinamic
 Palpation: right = left fremitus
 Percussion: sonor
 Auscultation: vesicular, rales -/- , wheezing -/-
 Cor:
 Inspection: ictus not seen
 Palpation: ictus is palpated at 2 finger lateral LMCS RIC VI
 Percussion:
 Left border: 2 finger lateral LMCS ICS VI
 Right border: linea sternalis dextra
 Upper border: RIC II
 Auscultation: pure rhythm, no murmur
Abdomen:

 Inspection: enlargement (-)
 Palpation: liver and spleen not palpable
 Percussion: tympani
 Auscultation: bowel sound (+)

Extremities:
 Physiologic Reflex +/+
 Pathologic Reflex -/-
 Oedema +/+
 Laboratory

Hb 11,3 gr/dl

PH 7,43
Ht 35% PCO2 40
WBC 7.570/mm3 PO2 141
Platelet 265.000/mm3 HCO3- 26,5
Ur/Cr 31/1,2 BEecf 2,2
Na/K/Cl 134/4,0/105 SO2 99%
RBG 530 mg/dl
Trop I 5,30


 Working Diagnosis
 NSTEMI Inferior

 CHF Fc II LVH RVH bradycardia sinus rhythm
cb ASHD
 Therapy

 Rest /heart Diet II/O2 2L/1’
 IVFD NacL 0,9% 500cc/24 hours
 Inj. Furosemid 1 x 20mg (iv)
 Inj. Arixtra 1 x 2,5cc (IM)
 Spironolactone 1 x 25mg (po)
 Ramipril 1x2,5mg (po)
 Clopidogrel 1x75mg (po)
 Aspilet 1x80mg (po)
 Simvastatin 1x20mg (po)
 Fluid balance
 Planning

 PCI
 Echocardiography