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MORNING REPORT

BAGIAN/SMF ILMU KARDIOLOGI


FAKULTAS KEDOKTERAN UNIVERSITAS
SYIAH KUALA
RUMAH SAKIT UMUM DR. ZAINOEL ABIDIN
BANDA ACEH

31 Maret 2015
NO

IDENTITAS

Ass

Plan

Basri,
47 Tahun,
Laki-laki

1. STEMI Anterior Ekstensif


2. DM Tipe II

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. Akut NSTEMI dd UAP tipe


Frist onset
2. Hipertensi Stage II

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

BAGIAN/SMF ILMU KARDIOLOGI


FAKULTAS KEDOKTERAN UNIVERSITAS SYIAH
KUALA
RUMAH SAKIT UMUM DR. ZAINOEL ABIDIN
BANDA ACEH

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 Penyakit Dahulu:


Pasien telah menderita diabetes mielitus sejak 2 tahun yang lalu.
Riw. Penyakit Keluarga:
Ayah pasien menderita hipertensi. Riwayat sakit jantung dan DM di
keluarga disangkal.

Riwayat Pengobatan:
Obat dari pulang rawatan di RS kesdam

Riwayat Kebiasaan Sosial:


Pasien sering mengkonsumsi rokok. Dalam 1 hari bisa stengah sampai 1
bungkus rokok yang dihabiskan. Pasien juga sering mengkonsumsi
makanan berlemak dan tidak pernah menjaga pola makan. Pasien juga
mengaku tidak teratur berolahraga.

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

: Simetris, retraksi (-)


: TVJ R-2 cmH2O, Pembesaran KGB (-)

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

: Simetris, distensi (-), vena kolateral (-)


: Nyeri Tekan (-)epigastrium, defans muscular (-)
: tidak teraba
: tidak teraba
: Ballotement (-)
: Timpani, shifting dullness (-)
: Peristaltik normal

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

Gula darah puasa

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

: Symmetric between left and right chest.


: No mass, no tenderness.
: Sonor between left and right chest, lungliver border in ICS IV right anterior .
Auscultation
:
Breath Sounds
: Vesicular
Adventitious breath sound
: Ronchi -/-, wheezing -/-

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.

: Flat and following breath movement


: Peristaltic sound (+), normal
: Liver and spleen is unpalpable
: Tympani (+), ascites (-)

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

4.0 10.0 x 103

RBC

4.86 x 106/l

4.0 6.0 x 106

HGB

15.0 gr/dl

12 16

HCT

44,6 %

37 48

PLT

141 x 103 /l

150 400 x 103

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

blood flow decreases


abruptly
after
a
thrombotic occlusion
of a coronary artery
previously affected by
atherosclerosis.
In
most
cases,
infarction occurs when
an
atherosclerotic
plaque
fissures,
ruptures, or ulcerates.

PATHOGENESIS
Lipid transport disorder

Inflamation

Plaque deposition

Erosion

Stable plaque
Thrombus

Stable angina pectoris

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

WHO DIAGNOSTIC CRITERIA


1. Clinical history of ischemic type chest
pain lasting >20 minutes
2. Changes in serial ECG tracings
3. Rise and fall of serum cardiac
biomarkers such as creatinine kinaseMB fraction and troponin

ECG CHANGES
Timing of myocardial infarction based on ECG

SERUM CARDIAC MARKER


ELEVATIONS

DIAGNOSIS
Signs of myocardial
ischemia
ECG
ST segmen elevation ?

No

Yes

Lab

Biochemical cardiac markers ?

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
(%)

No clinical signs of heart


failure

II

Rales or crackles in the lungs,


an S3, and elevated jugular
venous pressure

17

III

Acute pulmonary edema

30 - 40

IV

Cardiogenic shock or
hypotension (systolic BP < 90
mmHg), and evidence of
peripheral vasoconstriction

60 80

PROGNOSIS TIMI SCORE

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