BY :Juliet C G Umbas (C11108204)

SUPERVISOR :Prof. Dr. dr. Peter Kabo, Ph.D, Sp.FK, Sp.JP, FIHA

Case Report

• MR number : 607725• Name : Mr. E• Gender : Male• Age : 57 years old• Date administered : 27th April 2013

Chief complaint: Chest pain

• It was felt ± 12 hours ago before admitted to the hospital. The location

was at the center of the chest and penetrated to the back, and radiated to

the neck, jaw, and left arm. The pain was described as ‘squeezed’.

Duration of chest pain attack was around 20 minutes, triggered by

activity, and did not relieved by rest. During the attack, patient feel

shortness of breath, sweating and nausea. Vomit (-), epigastric pain (-),

cough (-), fever (-), PND (-), DOE (-)

Defecation and urination were normal

• History of hypertension (+) since 5 years ago but doesn’t

take medication regularly

• History of smoking (+) since 20 years ago (around 1 pack

per day)

• History of diabetes mellitus (-)

• History of dyslipidemia (-)

• Family history of CAD (-)

Modifiable :- Hypertension (+)- Obesity (+)- Smoking (+)

Non - Modifiable :- Male- Age >45 yo

• General status

Moderate illness/overweight/conscious

• Vital sign– Blood Pressure : 170/100 mmHg– Pulse : 86 x/min– Respiratory Rate : 22 x/min– Body Temperature : 36.50 C

Regional statusHead Examination

- Eyes : anemic -/-, icterus -/-- Lip : cyanosis (-)- Neck: lymphadenopathy (-), JVP R - 1 cmH2O

Chest Examination- Inspection : symmetric R=L, normochest- Palpation : mass (-), tenderness (-), VF R=L- Percussion : sonor- Auscultation : breath sound : vesicular

additional sound : ronchi -/-, wheezing -/-

Regional statusCardiac Examination

- Inspection : Ictus cordis wasn’t visible- Palpation : Ictus cordis wasn’t palpable- Percussion : normal heart size

-Upper border : left 2nd ICS-Lower border : left 5th ICS -Right border : right parasternalis line-Left border : left medioclavicular line

-Auscultation : Regular sound of I/II heart sound, murmur (-)

Abdominal Examination - Inspection : flat and following breath movement- Auscultation : peristaltic sound (+) , normal- Palpation : liver and spleen unpalpable- Percussion : tympani, ascites (-)

Extremities - No limb oedema

Chest X-Ray

• Conclusion: Cardiomegaly

with dilatation of aorta

Right diaphragm elevation

(intraabdominal process suspected)

Gambar x-ray

27 April 2013

Interpretation: (27/4/13)Rhythm : Sinus

QRS Rate : 62 bpm, regular

P wave : 0.1 sec

PR interval : 0.2 sec

QRS complex : 0.06 sec

Axis : Normoaxis, 15°

ST Segment : ST elevation V2– V5

T wave : inverted in III & V1

LABORATORY FINDINGS

RESULT NORMAL

WBC 6.30 [10^3/uL] 4.0-10.0

RBC 3.98 [10^6/uL] 4.00-5.00

HGB 12.9 [g/dL] 12.0-16.0

HCT 38.9 [%] 37.0-48.0

PLT 209[10^3/uL] 150-400

CK 760 [U/L] L(<190), P(<167)

CK-MB 52 [U/L] <25

TROPONIN-T >2.0 POSITIVE

LABORATORY FINDINGS

RESULT NORMAL

GDS 88 140

UREUM 48 10-50

CREATININE 0.8 L(<1.3), P(<1,1)

SGOT 29 <38

SGPT 37 <41

NATRIUM 143 136-145

KALIUM 4.9 3.5-5.1

CHLORIDE 110 97-111

Working Diagnosis

STEMI Anterior Wall Onset > 12 Hours KILLIP I

HT Grade II JNC 7

• O2 2-4 ltr/min

• Diet low sodium, low fat• IVFD NaCl 0,9 % 500 cc/ 24 hours• Fondaparinux 2,5 mg/24hr/SC• Aspirin 80 mg loading dose 2 tab 80 mg 0 – 1 – 0• Clopidogrel 75 mg loading dose 4 tab 75 mg 1 – 0 – 0• ISDN 5 mg / SL (if needed)• Captopril 12,5 mg 1-1-1• Bisoprolol 5mg 0-1-0• Alprazolam 0,5 mg 0 - 0 – 1• Laxadyn syr 0-0-2 tsp

PLANNING

• ECG serial• Echocardiography

• Myocardial infarction (MI) is the rapid development of

myocardial necrosis caused by an imbalance between

the oxygen supply and demand of the myocardium.

• This usually results from plaque rupture with thrombus

formation in a coronary vessels

• Myocardial infarction (MI) is the rapid development of

myocardial necrosis caused by an imbalance between

the oxygen supply and demand of the myocardium.

• This usually results from plaque rupture with thrombus

formation in a coronary vessels

DEFINITIONDEFINITION

Risk FactorModifiable Non-Modifiable

Smoking Men, increased risk after age 45

Hypertension Women, increased risk after age 55

Diabetes MellitusFamily history of heart disease

diagnosed before age 55 in father or brother

DyslipidemiaFamily history of heart disease

diagnosed before age 65 in mother or sister

Obesity

Lack of physical activity

TIMI Risk Score for STEMI

Historical

Age 65-74 1 point

>/= 3 Risk Factor for CAD 1 point

Known CAD Stenosis ≥ 50% 1 point

Aspirin use in last 7 days 1 point

Presentation

Recent (≤ 24h) severe angina 1 point

ST-segmen deviation ≥ 0.5mm 1 point

Elevated serum cardiac markers 1 point

Risk Score = Total (0-7)

1. Clinical history of ischaemic type chest pain lasting >20 minutes

2. Changes in serial ECG tracings3. Rise and fall of serum cardiac biomarkers

such as Creatinine Kinase-MB fraction and troponin

WHO Diagnostic Criteria

Clinical Features

• Duration : variable, often more than 30 minutes.• Quality : Feels squeezing, pressurelike, tightness,

heaviness, and burning. • Location : Retrosternal, often with radiation to or

isolated discomfort in neck, jaw, shoulders, or arms—frequently on left.

Associated features : Not relieve with rest or nitrat

• Fixing the chest pain and fearnesso Bed resto Diet o O2 2-4 lpmo Nitrate sublingual/oral/IVo Antiplatelet : aspirin and clopidogrelo Morfin/petidineo Diazepam 2-5mg/8 hour• Stabilizing the hemodynamic ( blood pressure and pheripheral pulse

control)o β-blockero Calcium chanel blocker (CCB)o ACE-Inhibitor• Reperfusion of the myocardo Thrombolitic

Class Description Mortality Rate (%)

I no clinical signs of heart failure 6II rales or crackles in the lungs, an S3,

and elevated jugular venous pressure17

III acute pulmonary edema 30 - 40IV cardiogenic shock or hypotension

(systolic BP < 90 mmHg), and evidence of peripheral vasoconstriction

60 – 80

PROGNOSIS