LAPORAN KASUS

ACUTE MYOCARDIAL INFARCTION

Disusun oleh :

Sri Sinta / 406162097

Pembimbing :

dr. Pujo Hendriyanto, SpPD

KEPANITERAAN KLINIK ILMU PENYAKIT DALAM

RUMAH SAKIT UMUM DAERAH K.R.M.T WONGSONEGORO

PERIODE 19 MARET – 26 MEI 2018

FAKULTAS KEDOKTERAN UNIVERSITAS TARUMANAGARA

JAKARTA
IDENTITAS PASIEN
Nama : Tn J Jenis Kelamin : Laki-laki
Usia : 50 tahun Suku Bangsa : Manado
Status Perkawinan : Duda Agama : Kristen
Protestan
Pekerjaan : Tidak bekerja Pendidikan : SMA
Alamat : Manado Tgl ke IGD : 5 April 2020

I. ANAMNESIS
Tanggal : 5 April 2020 Jam: 12.30
Keluhan Utama : Nyeri dada kiri
Keluhan Tambahan : Mual
Riwayat Penyakit Sekarang
Pasien datang ke UGD RS GMIM Pancaran Kasih dengan keluhan utama nyeri dada kiri
sejak 1 minggu terakhir. Nyeri dada kiri dirasakan hilang timbul selama <5menit.
Awalnya saat sedang bekerja di rumah, nyeri dada dirasakan membaik ketika istirahat ,
penjalaran nyeri hingga ke punggung belakang, nyeri diperberat oleh aktivitas dan lebih
membaik jika istirahat. Selama di rumah pasien belum mendapatkan obat-obatan.
Keluhan lainnya seperti mual (+) dirasakan hilang timbul, muntah (-), pandangan gelap
(-), berkeringat (-), batuk (-), nyeri menelan (-), demam (-), gangguan pendengaran (-).
BAK kuning jernih, darah (-), lancar, dan BAB 2 hari sekali, tinja berwarna kuning dan
padat biasa. Makan sehari 3x1 porsi, lauk beragam, suka makan babi dan gorengan, dan
minum air putih sehari 7-9gelas.

Riwayat Penyakit Dahulu

Alergi : Disangkal
Keluhan serupa : Nyeri dada (-)
Hipertensi : Disangkal
Diabetes : Disangkal
Penyakit Jantung : Ya
Penyakit Ginjal : Disangkal
Penyakit Tiroid : Disangkal
Asma : Disangkal
 Riwayat Penyakit Keluarga
Asma : Disangkal
Hipertensi : Disangkal
Diabetes : Disangkal
Penyakit Jantung : Disangkal
Penyakit Ginjal : Disangkal

Riwayat Kebiasaan
Merokok (-), minum alkohol (-), NAPZA (-)

Riwayat Sosial-ekonomi
Di lingkungan sekitar tidak ada yang mengalami keluhan serupa.
Pembiayaan pasien menggunakan BPJS Non PBI.

II. PEMERIKSAAN FISIK

Tanggal: 5 April 2020 Jam: 12.45 WIB
Pemeriksaan Umum
Keadaan umum : Tampak sakit ringan
Kesadaran : Compos mentis, GCS 15 (E4 M6 V5)
Tanda vital
Tekanan darah: 130/70 mmHg
HR : 68 x/menit, reguler, isi cukup
RR : 20 x/menit, reguler
Suhu tubuh : 36,2o C
SpO2 : 100%
Data Antropometri :
Berat badan : 52 kg
Tinggi badan : 158 cm
IMT : 20,8 kg/m2 – Normal
Pemeriksaan Sistem
o Kepala : normocephal, rambut putih tersebar merata dan tidak
mudah dicabut
 Mata : edema palpebra (-), bola mata simetris, konjungtiva anemis (-),
konjungtiva hiperemis (-) perdarahan subkonjungtiva (-), sklera
ikterik (-), kornea dan lensa jernih, pupil bulat isokor Ø 3mm.
Telinga : normotia, nyeri tekan tragus (-), nyeri tarik aurikula (-), nyeri
tekan mastoid (-), liang telinga lapang, sekret (-)
Hidung : simetris, napas cuping hidung (-)
Mulut : sianosis (-)
Tenggorokan : uvula berada di tengah, faring hiperemis (-), dendritus (-)
tonsil T1-T1, arcus faring simetris
o Leher : Trakea di tengah, tiroid tidak teraba membesar, bruit (-)
pembesaran KGB cervikal, supra dan infraclavicula (-)
o Thoraks
Inspeksi :
Bagian belakang :Bentuk dada bagian belakang normal, bentuk skapula simetris,
tidak ditemukan bekas luka ataupun benjolan, pergerakan dada
simetris tidak ada yang tertinggal
Bagian depan : Dada simetris, bentuk dada datar, tidak tampak deviasi trakhea,
tidak tampak adanya retraksi, pergerakan dada simetris tidak
ada yang tertinggal
Palpasi : Stem fremitus sama kuat dikedua lapang paru
Perkusi : Sonor di kedua lapang paru
Auskultasi : Suara dasar paru vesikuler (+/+), rhonki (-), wheezing (-)
o Jantung
Inspeksi : Iktus kordis tidak tampak
Palpasi :.Iktus kordis tidak teraba, tidak kuat angkat
Perkusi : Batas kiri ICS V midclavicular line sinistra
Batas atas ICS II parasternal line sinistra
Batas kanan ICS V sternal line dekstra
Auskultasi : Bunyi jantung I & II reguler, murmur (-), gallop (-)
o Abdomen
Inspeksi : tampak datar, simetris
Palpasi : supel, turgor kulit menurun, hepar dan lien tidak teraba
membesar, nyeri tekan epigastrik dan perut kiri atas (-)
Perkusi : timpani pada 4 kuadran
 Auskultasi : bising usus 8x/menit
o Ekstremitas : akral dingin (-), edema (-)
o Kulit : Ikterik (-) , CRT < 2 detik, palpitasi (-), tugor kulit menurun (-)
o Anus & Genitalia : tidak dilakukan pemeriksaan
o Kelenjar getah bening : tidak teraba membesar
o Pemeriksaan neurologis : N. Cranialis dbn

III. PEMERIKSAAN PENUNJANG

Tanggal 5 April 2020, jam 13.15

IV. RESUME
Telah diperiksa seorang laki-laki berusia 78tahun dengan keluhan utama nyeri dada kiri,
nyeri dada terakhir 4 jam yang lalu SMRS, selama lebih dari 30 menit, dalam 24 jam
terakhir nyeri dada >1x diperberat oleh aktifitas dan diperingan dengan istirahat tirah
baring, sesak nafas (+) 1hari SMRS serangan bersamaan dengan nyeri dada, pusing
berputar (+), mual (+).
Dari pemeriksaan fisik didapatkan Kardiomegali (ictus cordis 1 jari ke lateral dari ICS V
MCL Sinistra), aritmia (BJ ireguler), takipneu,
Dari pemeriksaan penunjang didapatkan peningkatan FT4.

V. DIAGNOSA
a. Diagnosa Utama : Angina pectoris stabil
b. Diagnosa Tambahan

VI. PENGKAJIAN
a. CLINICAL REASONING
Dari ananesa, PF, EKG mengarah ke angina pectoris stabil
DIAGNOSA BANDING
Unstable angina
AMI
GERD

b. RENCANA DIAGNOSTIK
 Melengkapi Rongen thoraks
Faktor resiko : kolestrol, LDL, HDL, trigliserida
Cek CKMB per 6/12 jam
Cek risiko pendarahan PT dan aPTT dan evaluasi ES heparin

c. RENCANA TERAPI FARMAKOLOGIS

Nasal kanul O2 2L/jam
Infus RL 12 tpm
Inj Ranitidin 2x1amp
Inj Ondansentron 4mg /12jam
Inj Omeprazol 20mg/ 12 jam
Inj Ketorolac 2x1amp atau morfin 2-4mg diulang interval 5-15mnt dg max 20mg
Inj Subcutan Enoxaparin 39U/12 jam ( >75th 0,75U/BB/12 jam slm 8 hr / sd PCI)
Sublingual Nitogliserin 0,4mg (max 3 dosis dengan interval 5menit)
Oral aspilet 1x 240mg (3tab)
Oral Betahistin 3x1 tab

d. RENCANA TERAPI NON-FARMAKOLOGIS

 Istirahat bed rest total

 Diet nutrisi yang adekuat.

 Menggali lebih dalam faktor resiko yang menunjang penyakit atau perburukan
penyakit.

e. RENCANA EVALUASI
 Evaluasi keluhan pasien, keadaan umum, tanda-tanda vital pasien dan tanda
perdarahan.
 Evaluasi laboratorium CKMB, elektrolit (Na, K, Ca), PT/APTT
 Evaluasi EKG
 Evaluasi keberhasilan terapi.

f. EDUKASI
 Menjelaskan kepada pasien dan keluarga tentang penyakit, penyebab, faktor
resiko, komplikasi, dan prognosis.
  Menjelaskan faktor yang memperberat dan memperingan gejala penyakit
pasien.
 Menjelaskan pentingnya minum obat dan kontrol teratur.
 Menjelaskan nutrisi yang adekuat dan istirahat cukup untuk menunjang
pemulihan pasien.
 Istirahat yang banyak dan menghindari aktifitas sedang-berat.

VII. PROGNOSIS
a. Ad vitam : Dubia ad bonam.
b. Ad functionam : Dubia ad bonam.
c. Ad sanationam : Dubia ad bonam.
Faktor resiko CAD
-Frammingham score : Usia, kolestrol, HDL, merokok, TD ( T > 20%, TM 10-20%, M<10%, R
0-1%
-SCORE : ST >= 10 %, T 5-9%, M 1-5%, R <1%
Resiko SKA
Goldman rule  TIMI (scores 0–7)
 Typical new onset chest pain
at rest
 Constricting discomfort in
the front of the chest, with
radiation to the neck, jaw,
shoulders or arms
 Pain the same as previous
MI
 Pain not relieved by own
GTN within 15 min
 Pain lasting more than
60 min
 Pain occurring with
increasing frequency
 Hypotension (SBP
<100 mmHg)
 Acute shortness of breath
 Pain within 6 weeks of AMI
or revascularisation
Very low risk: No to all
Low risk: Yes to 1
Intermediate risk: Yes to 2
or more
NHF AUS
  Age ≥65 years High-risk NSTE ACS
  ≥3 Risk factorsa for Presentation with clinical features
coronary artery consistent with ACS and any of:
disease
  Repetitive or prolonged (>10 min)
  Use of aspirin in the ongoing chest pain/discomfort
last 7 days
  Elevation of at least one cardiac
  Significant coronary biomarker (troponin or CK-MB)
stenosis (e.g. prior
coronary stenosis   Persistent or dynamic ST depression
≥50 %) >0.5 mm or new T wave inversion
>2 mm
  Severe angina (e.g.
≥2 angina events in   Transient ST segment elevation
last 24 h or persisting (>0.5 mm) in more than two contiguous
discomfort) leads
  ST-segment   Haemodynamic compromise: systolic
deviation of 0.05 mV blood pressure <90 mmHg, cool
on first ECG peripheries, diaphoresis, Killip class >1
and/or new onset mitral regurgitation
  Elevated troponin
and/or CK-MB on   Sustained ventricular tachycardia
initial blood tests
  Syncope
a
FHx of coronary
artery disease, HTN,   LV systolic dysfunction (LVEF <40 %)
hypercholesterolemia,
DM, or Smoker   Prior PCI within 6 months or prior
CABG surgery
Low risk: No to all
  Presence of known diabetes (with
Not low risk: Yes to typical symptoms of ACS)
1 or more
  Chronic kidney disease-estimated GFR
Prognosis—14 days <60 mL/min (with typical symptoms of
ACS)
PURSUIT (scores 0– GRACE (scores 0–258)
18)
  Age (>40 years in 10 year
 Age, separate points bands)
for enrolment diagnosis
  Heart rate (>70 bpm; in
 Decade bands [for UA bands of 10 up to
(MI); starting at >200 bpm)
50 years]
  Systolic BP (>80 mmHg
 Sex (male or female) in bands of 10 up to
>200 mmHg)
 Worst CCS-class in
previous 6 weeks   Creatinine (0 to >4 mg/dL
in bands of 0.39)
 No angina or CCS I/II
 Killip class (I, II, III, or
 CCS III/IV IV)
Intermediate-risk NSTEACS
Presentation with clinical features
consistent with ACS and any of:
  Chest pain or discomfort within past
48 h that occurred at rest, or was
repetitive or prolonged but currently
resolved
  Age >65 years
  Known CHD: prior MI with LVEF
>40 % or known coronary lesion >50 %
stenosed
  No high-risk ECG changes (see
above)

 Signs of heart failure   Cardiac arrest at   Two or more of: known hypertension,
admission family history, active smoking or
 ST-depression on hyperlipidaemia
presenting ECG   Elevated cardiac markers
  Presence of known diabetes (with
 Prognosis—30 days   ST-segment deviation atypical symptoms of ACS)

  Prognosis—events in   Chronic kidney disease-estimated

hospital GFR <60 mL/min (with atypical
symptoms of ACS)

  Prior aspirin use AND NOT meeting

the criteria for high-risk NSTEACS

Vancouver MARSAN et al Low-risk NSTEACS

In the final model, a patient was considered   Adults, 40 years Presentation with clinical
low-risk if either of the following criteria features consistent with ACS
were met:   No cardiac risk without intermediate- or
factors and/or high-risk features, for
 <40 years old, with a normal initial ECG, normal ECG example
and no prior history of ischaemic chest pain
At low risk (<1 %)   Onset of anginal symptoms
 ≥40 years old with normal ECG results, no for ACS and 30- within the last month; or
previous ischemic chest pain, low risk chest day adverse
pain characteristics, and either an initial cardiovascular   Worsening in severity or
creatine kinase-MB (CK-MB) <3.0 μg/L or events frequency of angina; or
an initial CK-MB ≥3.0 μg/L, but without an
increase or ECG changes within 2 h   Lowering in anginal
threshold
 HEART North American chest Vancouver chest pain diagnostic
pain rule algorithm

Composition of the HEART A patient with chest pain
score for chest pain patients and possible acute coronary
syndrome can be safely
 History discharged from the ED
without additional
  Highly suspicious 2 diagnostic testing if NONE
of the following criteria are
  Moderately suspicious 1   met:
  Slightly suspicious 0 (1) New ischemia on initial
ECGa
 ECG
(2) History of coronary
  Significant ST-depression 2
artery disease
  Non-specific repolarisation
(3) Pain is typical for acute
disturbance 1
coronary syndromeb
  Normal 0
(4) Initial cardiac troponin
 Age is positive AND
  ≥65 year 2 (5) Age ≤40 years OR
  45–65 year 1 Age 41–50 years and repeat
troponin at least 6 h from
  ≤45 year 0 symptom onset is
negativec , d
 Risk factors
  ≥3 Risk factors or history of
atherosclerotic disease 2
Patients are discharged with no
further investigations if deemed
very low risk by an ending
emergency physician
 0-h assessment. If yes to any of:
High risk clinical featurese, EKG
suspicious for ischemiaf, Initial
troponin positive,g then refer to
cardiology. If No then low risk. If
unclear then assess at 2 h.
 2 h assessment. If yes to any of:
New high risk clinical features,
EKG suspicious for ischemia, 2 h
troponin positive, then refer to
cardiology. If No then low risk. If
unclear then assess at 6 h.
 6 h assessment. If yes to any of:
New high risk clinical features,
EKG suspicious for ischemia, 6 h
troponin positive, then refer to
cardiology. If no then low risk. If
unclear then outpatient provocative
testing arranged within 48 hh.
 All low-risk patients followed up at
30 days.

  1 or 2 Risk factors 1

  No risk factors known 0

 Troponin

  ≥3 × Normal limit 2

  1–3 × Normal limit 1

  ≤Normal limit 0
a
Defined as ST-segment deviation greater than or equal to 1 mm or T-wave inversion greater
than or equal to 0.2 mm in at least 2 contiguous leads
b
As determined by the attending emergency physician. Samples for contemporary cardiac
troponin assay analysis were obtained at presentation and at least 6 h from symptom onset in
this cohort. Positive was defined as greater than 99th percentile reference limit
c
In addition, an age cutoff of 60 years or younger can be used with a less than 2 % miss rate
and lower proportion of patients who require urgent stress testing in practice settings in which
this miss rate is acceptable
d
Does not apply to patients with acute ST-segment elevation, hemodynamic instability, a clear
traumatic cause of chest pain, a history of cocaine use or tested positive for cocaine, a terminal
non-cardiac illness, or who were considered to have an unreliable history by the treating
physician
e
High-risk clinical features: hemodynamically unstable, typical crescendo angina, rest
pain > 20 min identical to past ACS, or on-going pain in ED
f
EKG suspicious for ischemia: ST elevationon > 2 mm in 2 precordial leads, ST
elevation > 1 mm in 2 inferior or lateral leads, ST elevation in right ventricular or posterior
leads, ST depression > 0.5 mm in 2 contiguous leads, pathologic Q waves in 2 contiguous
leads, or T wave inversion in 2 contiguous leads)
g
Troponin T elevation: (Roche Elecys, Hoffman LaRoche, Laval, PQ)
elevationon > 0.04 ng/mL
h
Although patients were typically referred at 0-, 2-, or 6-h decision points, they could be
referred any time if clinical status changed; therefore some referral and discharge times are
approximate