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CC I
NO
NAME
AGE
December 2015
DIAGNOSIS
Mr. Sp
57
Mr. Rw
56
Mr. M
60
Mr. TD
60
Mr. PD
27
FEMALE WARD
NO
NAME
AGE
DIAGNOSIS
Mrs. S
65
STEMI inferior
Mrs. Sl
54
CHF ec HHD
Mrs. SS
58
Mrs. SR
60
CC I
NO
NAME
DIAGNOSIS
201 1
Mr. K
46
Mr. N
62
STEMI inferoposterior
202 1
Mr. S
62
2
203 1
56
65
204 1
Mrs. S
29
Mrs. N
56
205 1
Mr. Sn
65
NSTEMI killip I
Mr. Z
44
Diagnosis
NSTEMI
CHF NYHA II ec IHD
PCI history in March 2015
Hypertension st II
Dyslipidemia
Case ilustration
Patient identity
Name
: Mr S
Age
: 66 yo
Adress
: Besani RT 4/RW 1
Occupation
: Retired
Recent history
Chief complaint : chest pain
At RSDK
Chest pain (+). Patient took
another ISDN sublingually. Pain
decreased a little in intensity.
Dyspnea (-), Palpitation (-),
syncope (-)
(+)
DM
(-)
Dyslipidemi (+)
a
PAST MEDICAL HISTORY
Gastritis
Asthma
Allergy
Stroke
Kidney disease
Alcohol abuse
Smoker
(-)
Family
history
(-)
Medication history
Miniaspi 80mg/24hour
Furosemide 40mg/24hour
Diltiazem 30mg/12hour
Clopisan 75mg/24hour
Simvastatin 10mg/24hour
Isonat 10mg/24hour
Spironolactone 25mg/24hour
Diovan 80mg/24hour
Family History
Hypertension (+)
There is no family member with
history of heart disease
PHYSICAL EXAMINATION
General Condition and Vital
Signs
-/-
Level of
Composmentis
consciousne
ss
Icteric sclera
-/-
Cyanotic lips
(-)
JVP
R +2
cmH2O
Hepatojugular
reflux
GCS
E4V5M6
General
condition
Moderately ill
Weight
60 kg
Height
165 cm
BMI
22,03 kg/m2
BP
160/100 mmHg
HR
92x/mnt
RR
18x/mnt
Temp
36C
SaO2
99
PHYSICAL EXAMINATION
Chest
HEART
Inspection
IC can be seen on 5th ICS, 2
cm lateral to LMCS
Palpation
IC was palpated on 5th ICS, 2
cm lateral to LMCS
Auscultation
Normal S1, S2
Murmur (-)
Gallop (-)
LUNG
Inspection
Symmetric while in static &
dynamic state
Palpation
Equal stem fremitus in both
lung fields
Percussion
Sonor
Auscultation
Vesicular +/+
Rales +/+, minimal at lungs
base
Crackles -/ Wheezing -/-
PHYSICAL EXAMINATION
Abdomen
Inspection
Flat
Auscultation
Normal
Percussion
Dull in right upper quadrant, shifting dullnes (-)
Palpation
Liver can be palpated 2 cm below arcus costae
Extremities
Warm extremities
Edema -/Cyanotic -/Gastrocnemeus pain -/Clubbing finger -/-
DIAGNOSTIC STUDIES
Laboratorium
PEMERIKSAAN
HASIL
SATUAN
NILAI NORMAL
13,3
g/dL
12,00 15,00
Hct
37,2
35 47
Eri
4,11
106/L
4,4 5,9
MCH
32,3
pg
27,00 32,00
MCV
950,4
fL
76 96
MCHC
35,8
g/dL
29,00 36,00
Leu
5,59
103/L
3,6 11
Trom
245
103/L
150 400
RDW
11,3
11,60 14,80
MPV
6,55
fL
4,00 11,00
PEMERIKSAA
HASIL
HASIL
SATUAN
NILAI NORMAL
KIMIA KLINIK
Fasting
89
mg/dL 80 109
PEMERIKSAAN
Glucose
2h
PP
98
mg/dl
80-140
glucose
HbA1C
5,7
6-8
23
177
U/L
7-25
mg/dL <200
CKMB
Total
25
Choleste
91
mg/dl
<150
de
HDL C
48
mg/dl
40-60
LDL C
102
mg/dl
0-100
Uric acid
6,2
mg/dl
3,5-7,2
mg/dl
15-39
Ureum
24
HASIL
SATUAN
NILAI
NORMAL
Creatinine
1,0
mg/dL
Mg
0,97
mmol/L
0,74-
mmol/L
0,99
2,12-
mmol/L
2,52
136-
Ca
Na
rol
Triglyceri
HASIL
2,15
140
0,6-1,3
3,6
mmol/L
145
3,5-5,1
Cl
106
mmol/L
98-107
Troponin
0,1
0,0
mcg/L
<0,01
THERAPY
Bed Rest
Inf RL 8 tpm
Inj. Arixtra 2,5 mg/24 jam intravena
Inj. Cedocard syringe pump 2mg/jam intravena
Inj. Furosemid 20mg/12jam intravena
Aspilet 80mg/24 jam intravena
Clopidogrel 75 mg/24jam
Valsartan 80mg/24jam
Spironolactone 25mg/24jam
Lansoprazole 30mg/24jam
Simvastatin 20mg/24jam
Biscor 2,5mg/24jam
PROGRAM
THANK YOU
CTR 59%. Elongatio aorta (+). Cardiac waist (-). Apex laterocaudal.
Increase bronchovascular markings. Right and left Costophrenic
angle are not sharp.