Duty report

April 11th, 2017

Armi 60 yo, IP 2

Chiefcomplain
Chest pain since 1 hours ago
 Present illness history
Chest pain since 12 ago. Pain like squeezed from pain
radiating to the back. The pain is approximately 20
minutes. Patients not previously experienced such
like this complaint
Shortness of breath (-)
Fever and cough (-)
Nausea and vomiting (+) since 1 days ago. But now
complaint (-)
Urination and defecation no complaints
History hypertension since 1 years ago

06/12/2017
Physical Examination
level of consciousness : CMC

BP : 150 / 90 mmHg

HR : 98 x/minute

RR : 21 x/minute

T: 37,2 oC
 Eye
Conjunctiva are anemic -/-
Sclera icteric -/-

Neck
JVP 5 - 2cmH20

Lung:
Inspection: simetric left = right
Palpation: fremitus left = right
Percussion: sonor
Auscultation: Vesicular, Rh -/- , Wh -/-

Cor:
Inspection: ictus is not seen.
Palpation: ictus is palpated at 1 finger lateral LMCS RIC VI
Percussion:
Left border: 1 finger lateral LMCS RIC VI
Right border: linea sternalis dextra
Upper border: RIC II
Auscultation: Pure rhythm, murmur (-)
 Abdomen:
Inspection: Enlargement (-)
Palpation: liver and spleen not palpable
Percussion: tympani
Auscultation: bowel sound (+) normal

Spine:
Pain of word -/-
Tenderness -/-

Extremities:
Physiologic Reflex +/+
Pathologic Reflex -/-
Oedema -/-
Laboratory
Examination Result
Hb 12,6 g/dl
Leukosit 10130 / mm3
Trombosit 230.000 / mm3
Ur / Cr 16 / 1
GDS 175

Hematokrit 40 %
PT / APTT 10,8/36,2
TROPONIN I 4,26

06/12/2017
Working Diagnose
NSTEMI
Hypertension heart disease
Therapy
Rest/ low salt IIheart diet II/02 3L/
Aspilet 1x 80 mg
Clopidogrel 1x 75 mg
Simvastatin 1x 40 mg
Ramipril 11x 2,5 mg
Bisoprolol 1x 2,5 mg
Spironolalkton 1x25 mg
ISDN ( If neeed )