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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