Mr Acs Nstemi
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Transcript of Mr Acs Nstemi
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8/10/2019 Mr Acs Nstemi
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Patient Identity Name: I Nengah Suarta
Sex: Male
Age: 75 yo
Religion: Hindu
Ethnicity/Nationality: Bali/Indonesia
Level of education: Graduated primary school
Marital status: Married
Job: None
Address: Banjar Tengenan Pegrisingan ManggisKarangasem
TC: 6.30 pm
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ANAMNESIS
Chief Complaint: Chest pain
Patient complained of pain in the chest since 2 daysBATH. The pain comes-and-go by itself The pain wasfelt like there was a weight on his chest. The patient alsofelt pain on his left shoulder and left arm. The painhappened suddenly and was felt for about 10 minutes.
Patients do not complain of cold sweat, palpitation, andbreathlessness.
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Past History
Patient have never experienced the same chief
complain before. History of hypertension, diabetes melitus, heart
disease and asthma was denied.
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Family History None of his family have same chief complain.
Family history of hypertension, diabetes melitus, heart
disease and asthma was denied.
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Social History The patient is currently not working and has been
leading a sedentary life about since 10 years ago (sincehe stopped working as a farmer).
Patient is a regular smoker who smokes > 1 pack/day.
Patient also consumes alcohol, but occasionaly.
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Eye : an -/-, ikt -/-, PR +/+ isocor
ENT :tonsil T1/T1, pharyngeal hyperemia (-) Neck: JVP PR 0 mmH2O Thorax : Symmetrical
Cor: S1, S2, single, regular, murmur (-)
Pulmo: Ves +/+, Rh -/- , Wh -/- Abdomen : Dist (-), Peristaltic N, Liver/Spleen: notpalpable.
Extremity: Warm + + Edema - -+ + - -
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ECG
Sinus rythm, 70bpm
Axis NST-T Changes: T inversion specific Lead V1/V2 (septal
ischemia)
Thorax Photo
Cor : CTR 61.4 %
Pulmo : WNL
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Chest X-Ray (AP)
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ECG
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AssesmentACS / NSTEMI / K I
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Therapy Hospitalized O24 Litres/minute ISDN drip 2mg/hour
Acetosal 1x160 mg Bisoprolol 1 x 2.5mg Clopidogrel 300mg -> 1 x 75 mg Diazepam 3 x 5 mg Enoxaparin 2 x 0.6 mL IVFD NaCl 0.9% 8 drops/minute Laxadyn 3 x CI Simvastatin 1 x 20mg (0-0-20)
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P/dx :
Lipid profile
Coronary Angiography
M/ :Vital sign
Symptom
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THANK YOU