Sept 26 , 2017
th
Chest pain
Present history
Patients present with chest pain since 1 week ago, complaints weigh
12 hours before entering the hospital. Pain is felt through the back
and radiates to the left arm, recurrent. Every attack > 15 menit.
Patients also complain short of breathness, weighing if walking into
the bathroom, sleeping with high pillows. Appetite has decreased
since this week. Defecate and urinate normally. Patient paralysis since
1 year ago, suddenly after waking up. Already treated to Soegiri
Hospital with TB bone diagnosis. Patients cough and short of
breathness, since that the activity assisted by wheelchair, but since
this week patients just feel asleep in a bed.
Past history of Illness
DM (-)
HT (-)
Family history
Social history
Laboratorium
GDA 139 Basofil 1,4 (0-1)
Kalium serum 2,9 (3,6-5,5) Eritrosit 4,09 (3,8-5,3)
Natrium serum 124 (135-155) Hb 11,4 (P 13-18 L 14-18)
Clorida serum 89 ( 70-108) Hct 36,2 (L 40-54 P 35-47)
Urea 31 (15-43) MCV 88,5 (87.00-100)
Serum creatinin 0,8 (P 0,7-1,2 MCH 27,90 (28.00-36.00)
L 0,8-1,5) MCHC 31,50 (31.00-37.00)
SGOT 20 ( 0-35) RDW 12 (10-16,5)
SGPT 18 (0-35) Trombosit 561 (150-450)
Leukosit 13,0 (4-11) MPV 4 (5-10)
Neutropil 78,0 (49-67) LED 1 : 99 (0-1)
Limfosit 16,0 (25-33) LED 2 : 110(1-7)
Monosit 3,5 (3-7)
Eosinophil 1,1 (1-2)
Re-Assesment
LBBB
Planning Therapy
O2 nasal 3 lpm
Inf RL 1500cc/24 jam
Inj Antrain 3x1 gr
Inj Ranitidin 2x50mg
Inj Ceftriaxone 2x1
Premix KCL 24 meq/24 jam
Tab ISDN 3x5 mg
Tab ASA 1x100mg
Tab simvastatin 1x10mg
Consul with cardiology
PLANNING MONITORING
Vital Signs
Patients complaint
Adverse effect
PLANNING EDUCATION
Explain to the patient and his family about the disease, cause,
complication, intervention of the therapy and prognosis.