Aps Nabila
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Transcript of Aps Nabila
LABORATORY FINDINGS
STABLE ANGINA PECTORISBy : Fawza Nabila FaudziSupervisor : dr. Pendrik Tandean, SpPD-KKV. FINASIMPATIENTS IDENTITYNAME: Mr. TBIRTH DATE : 09-03-1966 (48 years)ADDRESS: Attang Salo Kab PangkepMEDICAL RECORD : 426285DATE OF ADMISSION : 17th December 2014HISTORY TAKINGChief Complaint : Chest painPresent Ilness History : He has been suffering from increasing chest discomfort for the past 1 year. About 6 months ago, he noted that the chest pain episodes had become more frequent. Described as chest pain radiating to the left arm, duration of pain : less than 5 minutes, pain is precipitated by stress or physical activities, but always resolved with rest. No shortness of breath and no nausea.HISTORY TAKINGPast Ilness History :Neuropathy was diagnosed during a clinic visit 3 months ago; he takes carbamazepin 3 times per day and sohobion 1 tablet daily.
Social Life:Smoked 1 pack of cigarretes per day for the past 10 years.Drink beer occasionally
RISK FACTORNon Modifiable :Gender : Male Age > 45 years
Modifiable :Obesity (169cm height; 80cm weight) SmokingAlcohol
PHYSICAL EXAMINATIONGeneral StatusModerate illness/ Overweight/ Compos MentisWeight: 80 kgHeight: 169 cmBMI: 28,5 kg/m2Vital StatusBlood pressure : 130/80 mmHgHeart rate :76 bpmRespiratory rate : 20 bpmTemperature : 36,5 oC
ELECTROCARDIOGRAM
Sinus rhythmHeart rate : 64bpmAxis : Left Axis DeviationP Wave : 0.10 sPR interval : 0.20 sQRS Complex: Duration : 0,12 s Configuration : Q pathologic at V1, V2, V3, V4, V5ST segment : ST elevation at V1, V2, V3, V4, V5
Conclusion :Sinus rhythm, HR 64 bpm, left axis deviation, STEMI Whole Anterior
RADIOLOGY (CXR)-Cardiomegaly with dilatation, elongation et atherosclerosis aortae-Right diaphragm elevation
LABORATORY FINDINGSHemoglobin13.4 gr/dlLeucocyte12.0 x 103/uLThrombocyte390 x 103/uLPlasma glucose 147 mg/dlElectrolyte Sodium (Na) : 143 mmol/lPotassium (K) : 3.6 mmol/lChloride (Cl) : 104 mmol/l CK34.00 U/LCK-MB11.5 U/LTroponin T