Advisor :

dr. H. M. Saugi Abduh , Sp.PD

Name
Age
Sex
Job
Religion
Status
No. RM
Room
Entry Date
Exit Date

: Mrs. S
: 59 years old
: Female
: Housewife
: Moslem
: PBI
: 104.63.60
: Baitul Izzah 2 (410.3)
: June 21st 2014
: June 30th 2014

Main Complaint : Chest pain

Patient came to the hospital and complained
chest pain in the midle after lifted the heavy
thing. The chest pain occurred more than
half an hour. The characteristic of this pain
like a pressed in her chest and spread until
her back. She feel the pain lost and found,
and become better after took a rest. And the
other complained are dyspneu when activity,
cold sweat, tremble and she feel weakness.

History of Same Illness (-)

Hypertension History (+)
DM History (-)
Heart Dissease History (-)
Gastritis History (+)
History of Drug Allergy (-)

No family has the same illness

The medication fee guaranteed by PBI

General
: Weakness
Skin
: Itch (-), Wound (-), Jaundice (-), Pale (+)
Head
: Dizziness (-)
Eyes
: Red eye (-), anemic conjunctiva (-),
jaundice
sklera (-)
Ears
: Hearing loss (-), ringing (-), discharge (-)
Nose
: Epistaxis (-), Discharge (-)
Mouth : Sianosis (-), Sprue (-), Bleeding gums (-)
Troat
: Sore troat (-), Hoarseness (-), Disfagia (-)

Neck
: Swelling (-), neck stiffness (-),
Chest : Chest pain (+), palpitation (-)
GIT
: Appetite (-), Nausea (-), vomit (-),
hematemesis (-),
defecation
abnormality (-),
abdominal
pain (-)
Urogenital
: dysuri (-), hematuri (-), tea colour of
urination (-)
Musculoskeletal : parestesia (-), Low Back Pain (-)
Extremity
: oedem (-/-), parestesia (-/-), wound
(-/-)

Patient Status
Age : 59
years old
Sex : Female
Nutrient Status
weight : 50 kg
Height : 150 cm
BMI = 50
(1,5)2 =
22,22

Vital Sign
BP :
mmHg
HR :
RR :
T
:

130/90
79 x/m
24 x/m
36 C

Head : Mesocephal (-)

Eyes : conjunctiva anemic (-/-), jaundice
sklera (-/-)
Nose : Nostril breath (-), discharge (-)
Ears : Discharge (-),
Troat : Hiperemi (-)
Mouth : Cyanosis (-), Dry Lips (-)
Neck : Lympadenopati (-), Jugular vein
distention (-)

Inspection

Ictus cordis cant be seen

Palpation

Ictus cordis palpable by 1 points of finger at 1

cm lateral from ICS V linea midcalvicularis
sinistra, thrill (-), pulsus intercostalis (-),
pulsus epigastric (-), pulsus sternal lift (-)

Percussion
Upper borderline
: ICS II linea sternalis sinistra
Waist : ICS III linea parasternalis sinistra
Lower right borderline
: ICS V linea sternalis dextra
Lower left borderline
: ICS VI linea
midclavicularis
sinistra

Auscultation
Aorta valve
: S1 & S2 standard, additional sound (-)
Pulmonal valve
: S1 & S2 standard, additional
sound (-)
Trikuspidal valve
: S1 & S2 standard, additional
sound (-)
Mitral valve
: S1 & S2 standard, additional sound (-)

Anterior

Posterior

Static
Inspection

RR : 28x/min, Hyperpigmentation (-),

tumor (-), inflammation (-), spider
nevi (-), Hemithorax D=S, ICS
Normal, Diameter AP < LL

RR : 28x/min,
Hyperpigmentation (-), tumor
(-), inflammation (-), spider
nevi (-), Hemithorax D=S, ICS
Normal, Diameter AP < LL

Dynamic
Inspection

The movement of hemitorax D=S,

abdominothorakal breathing (-),
muscle retraction of breathing (+)

The movement of hemitorax

D=S, abdominothorakal
breathing (-), muscle retraction
of breathing (+)

Palpation

Palpation pain (-), tumor (-), Arcus

costae angle < 900, enlargement of
ICS (-),
Stem fremitus D=S

Palpation pain (-), tumor (-),

Arcus costae angle < 900,
enlargement of ICS (-),
Stem fremitus D=S

Percussion

Sonor +/+

Sonor +/+

Auscultation

ronchi (-) , wheezing (-) , vesikuler

(+) D=S

ronchi (-) , wheezing (-) ,

vesikuler (+) D=S

Inspection:
Symetric, sycatric(-), striae(-), squama(-)
enlargement of vena (-),
hyperpigmentasi (-), spider nevi (-),
caput medussae (-)
Auscultation :

Peristaltic (+) Normal (11 x/ minutes)

PERCUSSION
shifting dullness (-),
undulation test(-)
Hepar : deaf (+), liver
span dextra 10 cm, liver
span sinistra 7 cm
Lien : troube space (+)

PALPATION
Superfisial :
mass (-), abdominal pain
(-), costovertebral knock
pain (-)
Deeper :
Abdominal pain (-) ,
hepar is not palpable,
lien is not palpable,
kidney is not palpable.

Superior

Inferior

Oedem

-/-

-/-

Pitting Oedema

-/-

-/-

Cyanotic

-/-

-/-

Cold Extremity

-/-

-/-

Capillary Refille

-/-

-/-

Clubbing Finger

-/-

-/-

Laboratory
Examination

Results

Normal Value

Hb

12,5

11,7-15,5

Ht

38,6

33 45

Leucocyte

8,5

3,6 11,0

Trombocyte

226

150 440

Golongan Darah

O / Rh +

APTT

24,4

25 - 35

Protombin

12,5

9,9 13,3

Laboratory
Examination

Results

Normal Value

Cholesterol

190

< 200

Trigliserida

59

< 160

HDL

38

37-92

LDL

143

60 130

Uric Acid

11,6

3,5 - 7,2

GDS

168

75 110

Ureum

25

10 50

Creatinin

0,59

0,5 0,9

SGOT

28

0 35

SGPT

19

0 35

Laboratory
Examination

Results

Normal Value

Na

142,8

135 147

3,04

3,5 5

Cl

104,7

95 105

albumin

3,76

3,4 4,8

CKMB

15

<24

Laboratory
Examination
HBsAg Kualitatif

Results
Non Reaktif

Normal Value
Non Reaktif

Rhytm
: Reguler
Frequency
: 1500/18 = 83
Axis
: NAD
Transisional zone: unrecognize
P wave : Duration : 0,08s; Amplitudo : 0,2mV (N)
PR interval
: Duration : 0,08s (N)
QRS Kompleks : Duration : 0,12s (N)
ST Segmen
: ST elevation in Lead V2, V3, V4
( anteroseptal)
T wave : no T inverted/ T peak (Normal)
Other
:Conclusion
: STEAMI

Cor : Cardiomegali (LV)

Pulmo : Normal

History Taking
Chest pain
Dyspneu
Cold sweat
Tremble
Weakness
Hypertension
history (+)
Gastritis history
(+)

Physical
Examination
Cardiomegali
Dyspneu
Hypertension

Laboratory and
Radiology
Examination
Ro Thoraks :
Cardiomegali
ECG
:
ST
Elevation in Lead
V2,3,4
(anteroseptal)
Lab
:
Hyperurisemia
Hyperglikemi

AMI
Cardiomegali
Hypertension

Asessment : STEAMI, Non STEAMI

IpDx : ECG
IpTx :

Non Pharmacology :
Bed rest
Oksigen canul 2-4 lpm

Pharmacology :
Nitrogliserin
Aspirin

0,4 mg
80 mg

IpMx : Vital sign, ECG

IpEx :
Dont eat too much
Using sitting toilet
Decrease activity

tab
tab

3x1
1x1

Asessment : HHD, VHD, IHD, Anemic Heart

Disease
IpDx : ECG, Rontgen, Echocardiography
IpTx :

Non Pharmacology :
Bed rest
Oksigen canul 2-4 lpm

Pharmacology :
Bisoprolol
Spironolakton

5 mg
25 mg

tab
tab

IpMx : Vital sign, ECG, Rontgen

IpEx :
Dont eat too much
Using sitting toilet

3x
3 x1

Ass : Hipertension malign, hipertension

malign
IpDx : Funduscopy, Profil lipid
IpTx :

Non Pharmacology :
Low salt intake

Pharmacology :
Furosemide
Captopril

inj
2x1
25mg 2x1

IpMx :

Vital Sign

IpEx :
Diet low salt
Consumption vegetable, fruit
Routine consumption drugs