Presentation NSTEMI

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NSTEMI SITI NUR AMIRA M. NASIR C 111 10 875 Supervisor: dr. Pendrik Tandean, Sp. PD-KKV FINASIM

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Powerpoint Laporan Kasus Non ST Elevation Miocardiac Infarct

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NSTEMISITI NUR AMIRA M. NASIRC 111 10 875Supervisor: dr. Pendrik Tandean, Sp. PD-KKV FINASIM

Patient IdentityName: Mr. AHSex: MaleAge: 48 years oldAddress : JakartaOccupation: Government employerStatus: MarriedDate of admission: 20th March 2015Medical Record No.: 705554Room: Emergency room

AnamnesisChief complaintChest pain

Patient complaining about his chest pain since 5 days ago. The pain described as pressure, continuous and radiating to the patients back, jaw and his left arm. Duration of the pain more than 20 minutes. The pain not been aggravated by any activity and relieved with resting. He also complaint about dyspnea of effort , orthopnea, and paroxysmal nocturnal dyspnea. Sometimes he had cough with no phlegm and blood. Heartburn have been denied. Nausea and vomiting have been denied.

History of diseaseHistory of hospitalized one day at RS Pelamonia with same complaintHistory of lifestyle, smoking since 25 years ago, 2 packs per dayHypertension since 5 years ago and controlledDiabetes Mellitus and cholesterol disease have been deniedPhysical examinationGeneral statusGCS 15 (E4M6V5)BW : 60 kg, BH : 165 cm, BMI : 22 kg/m2 (normal)Moderate sickness / well nourished / conscious

Physical examinationVital signsBlood pressure: 170/90 mmHgPulse: 78x/minuteRespiratory rate : 22x/minuteAxilla Temperature: 36,5oC

Physical examinationHead and neck examinationEyes : Anemia (-), Icteric (-)Lips:Cyanosis (-)Neck: JVP R+2 cmH2O

Physical examinationThorax examinationInspection : Symmetrical left & rightPalpation:Tumor mass(-), tenderness (-)Percussion: Sonor left & right, limit of liver-lung at 4th ICS Auscultation: BP: vesicular, Addition sounds : ronchi +/+, wheezing -/-

Physical examinationHeart examinationInspection:Ictus cordis cannot be seenPalpation:Ictus cordis non-palpablePercussion:DullSuperior margin at left of 2nd ICS Right margin at right 4th ICS of parasternal lineLeft margin at left 5th ICS of midclavicular lineAuscultation:BJ : S I/II pure, regularPhysical examinationAbdomen examinationInspection:Flat, followed breathing movement Auscultation:Peristaltic sound (+) within normalPalpation:Tumor mass (-), epigastric tenderness (-), liver and spleen non-palpablePercussion:Tympani (+)Extremities examinationLeg edema -/-

LaboratoriumTESTRESULTWBC11.1 x 103 /mm34,0 - 10,0 x 103 /mm3RBC5,30 x 106 /mm34,0 - 6,0 x 106 /mm3Hb15,9 g/dl12,0 - 16,0 g/dlHct46,1 %37,0 - 47,0 %Plt311 x 103 /mm3150 - 400 x 103 /mm3Ureum30 mg/dl10 - 50 mg/dlCreatinin0,9 mg/dlL(