31 Maret 2015
NO
IDENTITAS
Ass
Plan
Basri,
47 Tahun,
Laki-laki
1. Rawat ICCU
2. dr/ur/cr/elektrolit/
kolesterol
lengkap/ as. Urat/
GDS/ CKMB/
Troponin I
3. Urinalisa
4. ECHO
5. Foto Thorax
Ainon Mardhiah,
69 tahun,
perempuan
1. Rawat ICCU
2. dr/ur/cr/elektrolit/
kolesterol
lengkap/ as. Urat/
GDS/ CKMB/
Troponin I
3. Urinalisa
4. ECHO
5. Foto Thorax
STEMI ANTERIOR
EKSTENSIF ONSET >2
JAM KILLIP I TIMI RISK
SCORE 1/14??
Disusun oleh:
Edho Biondi Joris
Supervisor :
dr. ,Sp.JP,FIHA
Identitas Pasien
Nama
: Tn. B
Umur
: 47 Tahun
Alamat : Indrapuri
Agama : Islam
Status Perkawinan
: Menikah
Suku
: Aceh
Nomor CM
: 0-98-78-70
Pekerjaan : PNS
Tanggal masuk : 31 Maret 2015
Anamnesa
Keluhan Utama: Sesak nafas
Riw. Penyakit Sekarang:
Pasien datang dengan keluhan sesak nafas, sesak nafas
dirasakan sejak sore sekitar
Occurred since about 7 hours before admitted to the hospital. On
the left side the chest pain feels dull heavy pain, it seems to
radiates to the back. It does not radiate to the shoulder/arm.
Chest pain last for 30 minutes. The pain is not lessen at rest or
with medication.
Patient had experienced chest pain for a year long.However,
patient did not check it to the hospital, because at that time the
pain it did not disturb his everyday activities and lessen at rest.
The chest pain accompanied with shortness of breath, cold
sweat (+), fever (-), cough (-), nausea (+), vomit (+), epigastric
pain (-). Defecation and urination normal.
Riwayat Pengobatan:
Obat dari pulang rawatan di RS kesdam
Pemeriksaan Fisik
Kesadaran
: CM (E4M6V5)
Tekanan Darah
Nadi
Pernafasan
Suhu
: 120/80 mmHg
: 83x/menit
: 28 x/menit
: 36,7 oC
Status Internus
Kepala
Rambut
: Hitam
Wajah
: simetris, oedema (-), deformitas (-)
Mata : Conjunctiva pucat (-/-), ikterik (-/-),
refleks cahaya (+/+),
Pupil bulat isokor 3 mm/3mm
Telinga
: Serumen (-/-)
Hidung
: Sekret (-/-)
Status Internus
Mulut
Bibir : Simetris, bibir pucat (-), mukosa basah (+), sianosis (-)
Lidah : Tremor (-), hiperemis (-)
Tonsil : Hiperemis (-/-), T2 T2
Faring: Hiperemis (-)
Leher
Inspeksi
Palpasi
Status Internus
Thorax
Inspeksi
Statis : Simetris, bentuk normochest
Dinamis
:
Pernafasan thoracoabdominal, retraksi
suprasternal (-), retraksi intercostal (-),
retraksi epigastrium (-)
Palpasi
: NT (-), Stem fremitus kanan = stem fremitus
kiri
Perkusi
: Sonor/Sonor
Auskultasi : Vesikuler (+/+), Rhonki (-/-), Wheezing (-/-)
Status Internus
Jantung
Inspeksi:
Ictus Cordis tidak terlihat
Palpasi:
Ictus cordis teraba
di ICS V linea axillaris anterior
Perkusi:
Batas jantung atas di ICS III
LMCS
Batas jantung kanan di ICS V
Linea
Parasternalis Dekstra
Batas jantung kiri di ICS V linea
axillaris anterior
Auskultasi :
BJ I > BJ II, regular, bising (-),
gallop (-)
Status Internus
Abdomen
Inspeksi
Palpasi
Hepar
Lien
Ginjal
Perkusi
Auskultasi
Status Internus
Genitalia
: Tidak diperiksa
Anus
: Tidak diperiksa
Kelenjar Limfe
Pembesaran KGB
: Tidak ada
Status Internus
Ekstremitas
Udem
Pucat
Gambaran EKG
Irama: aritmia
Rate : 120x/i
Axis : Normoaxis
Gel P : sulit dinilai
PR Interval: sulit dinilai
QRS duration: 0,08 s
ST elevasi
: ST depresi
: T inverted
: -
Kesimpulan :
AF RVR
Pemeriksaan Laboratorium
Pemeriksaan Laboratorium (31 Maret 2015)
Jenis Pemeriksaan
Hemoglobin
20/3/2015
13,7
Nilai rujukan
14-17 gr/dl
Leukosit
9,2
4.1-10.5 x 103/ul
Trombosit
500
150-400 x 103/ul
Hematokrit
40
45.0-55.0 %
Ureum darah
43
13-43 mg/dl
Creatinin darah
1,80
0.51-0.95 mg/dl
329
<200 mg/dl
Eritrosit
5,3
4.5-6.0 x 103/ul
Natrium (Na)
135
135-145 mmol/L
Kalium (K)
4,7
3.5-4.5 mmol/L
Klorida (Cl)
90
90-110 mmol/L
Troponin 1
5,52
CK-MB
48
<1,5 ng/mL
<25 U/L
Foto Thorak
Cor = Bentuk normal
dan ukuran membesar
ke kiri
Pulmo = tak tampak
infiltrat
Sinus phrenicocostaslis
kanan dan kiri tajam
Kesimpulan= Cardiomegali
Diagnosa
1. STEMI Anterior Ekstensif
2. DM Tipe 2
Terapi
Bed rest
02 2-4 l/i
IVFD RL 10 gtt/I
Proxime 1x1
Pantoprazole 2x1
Pravastatine 1x20mg
Tanapress 5mg 2x1/2 tab
Farsorbid 5mg 3x1 tab
Miozidine 2x1
Clopidogrel 75mg 1x1
Sc Lovenox 2x0,6cc
TERIMA KASIH
HISTORY TAKING
PHYSICAL EXAMINATION
General Status
Moderate Ilness/ Overweight/Conscious
Body Weight
:70 kg
Body Height :170 cm
Body Mass Index : 24,2 kg/m2
Vital Signs
BP
: 150/100mmHg
HR
: 96 bpm, regular
RR
: 28 bpm
T
: 36,5C
PHYSICAL EXAMINATION
Head and Neck Examinations:
Eye
: Conjunctiva anemic (-/-), Sclera icteric (-/-)
Lip
: Cyanosis (-)
Neck
: JVP R +2 cmHO
Chest Examination
Inspection
Palpation
Percussion
PHYSICAL EXAMINATION
Cardiac Examination
Inspection
: Heart apex was not visible
Palpation
: Heart apex was not palpable
Percussion
: Dull, left heart border left
midclavicular line ICS V.
Auscultation : Heart Sounds : S I/II regular,
murmur (-) gallop(-)
PHYSICAL EXAMINATION
Abdominal Examination
Insp.
Ausc.
Palp.
Perc.
Extremities
Oedema : Pretibial -/-, Dorsum pedis -/-
ELECTROCARDIOGRAM (ECG)
ECG :Sinus rhythm,
QRS rate 83 bites/
minute, north west
axis, PR interval
0,16 s, P wave 0,08
s, QRS comlex 0,08
s, Q patologis III,
aVF, V1-V3
ST segment
elevation V1-V5
Conclution : sinus
rhythm, HR 83
bite/minute, whole
anterior acute
myocard
infraction , old
myocard infraction
inferior
ELECTROCARDIOGRAM (ECG)
ECG :Sinus rhythm,
QRS rate 93 bites/
minute, right axis
devilation, PR
interval 0,12 s, P
wave 0,08 s, QRS
comlex 0,08 s, Q
patologis in III, aVF,
V1-V3
ST segment
elevation in V1-V5
Conclution : sinus
rhythm, HR 93
bite/minute, whole
anterior acute
myocard infraction ,
old myocard
infraction inferior
Laboratorium Finding
Complete blood count
Test
Result
Normal value
WBC
9,05 x 103/ul
RBC
4.86 x 106/l
HGB
15.0 gr/dl
12 16
HCT
44,6 %
37 48
PLT
141 x 103 /l
Blood Chemistry
Test
Result
Normal value
GDS
141 mg/dl
<140
Ureum
33mg/dl
10 50
Creatinine
0,9 mgr/dl
< 1.3
SGOT
24u/l
<38
SGPT
21 u/l
<41
Total Chol
HDL Chol
LDL Chol
123 mg/dl
23mg/dl
99 mg/dl
<200
> 55
< 130
Cardiac Enzymes
Test
Result
Normal value
CK
211U/L
<190
CK-MB
10 U/L
<25
Troponin-T
<0.02
<0,05
Electrolyte
Test
Result
Normal value
Na
145 mmol/l
136-145
3.5 mmol/l
3.5-5.1
Cl
110 mmol/l
97-111
CHEST X-RAYS
Cloudy parahilar accompanied
with cardiovascular suprahilar
dilatation on both lungs
There is no specific active
process seen on both lungs
Cor CTI widen 0,57 cm, aorta
dilated and calcified
Both sinuses and diaphragma
in good condition
Bones intact
Impression:
Cardiomegaly with signs of
Pulmonary edema
dilatation et atherosclerosis
aorta
WORKING DIAGNOSIS
1. ST elevation myocardial infarction
(STEMI) whole anterior onset >6 hours
KILLIP I,
2. Old myocard infraction inferior
3. Grade I hypertension
MANAGEMENT
O2 2 -4 Lpm
IVFD NaCl 0,9% 10 drops/min
Aspilet 80 mg 0-1-0 Aspirin (Antiplatelet)
Plavix 75 mg 0-0-1 Clopidogrel (Antiplatelet)
Injection ISDN 0,5 mg/hours/SP Nitrat
Captopril 25 mg 1-1-1 ACE-Inhibitor
Simvastatin 20 mg 0-0-1 Statin
(Anticholesterol)
Alprazolam 0,5 mg 0-0-1 Antianxietas
Laxadyn syr 0-0-2 c
PLANNING
Coronary angiography
STELEVATIONMYOCARDIAL
INFARCTION
DEFINITION
Myocardial infarction (MI)
rapid development of
myocardial
necrosis
caused
by
a
critical
imbalance between the
oxygen supply and demand
of the myocardium.
This usually results from
plaque
rupture
with
thrombus formation in a
coronary vessels, resulting
in an acute reduction of
blood supply to a portion of
the myocardium.
PATHOPHYSIOLOGY
Occurs when coronary
PATHOGENESIS
Lipid transport disorder
Inflamation
Plaque deposition
Erosion
Stable plaque
Thrombus
Thrombosis
Plaque rupture
Acute coronary syndrome:
Unstable angina
Myocardial infarction :
- Non Q waves
- Q waves
RISK FACTOR
Non- Modifiable
Gender and Age
Men, increased risk after age 45
Women, increased risk after age 55
Family History
Heart disease diagnosed before
age 55 in father or brother
Heart disease diagnosed before
age 65 in mother or sister
Modifiable
Smoking
Hypertension
Diabetes Mellitus
Dyslipidemia
Obesity
Lack of physical activity
CLINICAL
MANIFESTASION
Prolonged pain (usually >20
minutes) constricting,
crushing, squeezing
Usually retrosternal location,
radiating to left chest, left arm;
can be epigastric
Dyspnea
Diaphoresis
Palpitations
Nausea/vomiting
ECG CHANGES
Timing of myocardial infarction based on ECG
DIAGNOSIS
Signs of myocardial
ischemia
ECG
ST segmen elevation ?
No
Yes
Lab
No
Yes
STEMI
Acute Myocardial
Infarction
( Q-wave, non-Q wave )
NSTEMI
(No ST-Segment
Elevation
Myocardial Infarction)
Unstable Angina
INITIAL TREATMENT
1.
2.
3.
4.
Bed Rest
Diet
Oxygen (2-4L/mnt)
Anti platelet therapy :
Aspirin 160-325 mg chewed immediately and 81-162 mg
continued indefinitely.
Clopidogrel 300-600 mg loading dose and 75 mg daily
continued for at least 14 days and up to 12 months
5. Nitroglycerin
ISDN 10 mg or 20 mg, 2-3 a day.
ISDN 5 mg SL when chest pain.
INITIAL TREATMENT
6. Morphine 2,5-5 mg or pethidin 12,5-25 mg iv
7. ACE I (Captopril 12,5-25 mg )
8. Fibrinolytic therapy:
a) Streptokinase 1.5million units iv
b) Tenecteplase 0.5mg/kg body weight iv.
9. Anticoagulation therapy:
a) Low Molecular Weight Heparins ( Fondaparinux)
2.5mg/24hrs/sc for up to 8 days post-MI.
10. Statins
Simvastatin 20 mg
PROGNOSIS
KILLIP CLASSIFICATION
Clas
s
Description
Mortality Rate
(%)
II
17
III
30 - 40
IV
Cardiogenic shock or
hypotension (systolic BP < 90
mmHg), and evidence of
peripheral vasoconstriction
60 80
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