DEPARTMENT
Patient Identity
Name
: Mrs. RA
Age
: 52 years old
Register no.
: 725684
Date of admission :
Sept, 26th
2015
History Taking
Chief complaint : Chest pain
History taking :
It has been felt 4 hours before admitted to the
Risk Factor
MODIFIABLE :
Physical Examination
General Appearance : Moderate-
illness/normal BW/conscious
Vital Sign :
Head Examination :
Thoracic Examination :
Inspection
: Symmetric left
and right
Palpation
: No mass, no
tenderness
Percussion
: Sonor
Auscultation
: Breath Sound :
vesicular, Rh -/-, Wh -/-
Cardiac Examination :
Inspection
Palpation
palpable
Percussion : Pecac(+), heart size
increase
Auscultation
: Regular of I/II
Heart Sound, murmur (-)
Abdominal Examination :
Inspection
Extremities :
Radiology Finding
Conclusion :
Cardiomegal
y with
dilatation
aortae
ECG Interpretation
26th September 2015
Rhythm: Sinus rhythm
P wave : 0,04 s
Heart Rate : 103 bpm, Irreguler
PR interval : 0,12 s
Duration QRS : 0,12 s
Konfiguration
: Q wave V1-V6
Axis : Normoaxis
ST Segment : ST-Elevasi pada Lead V2, V3, V4,
V5, aVL
Laboratory Findings
26 th september 2015
Complete blood count
WBC : 9,6 x 103 /ul
HGB : 13,1 gr/dl
HCT : 38,9 %
PLT : 1322 x 103 /ul
Enzyme
CK : 199 mmol/l
CK-MB
: 21,6 mmol/l
Troponin I : 0,35
mmol/l
Blood chemistry
Ureum : 25 mg/dl
Creatinine : 0,79 mg/dl
SGOT/SGPT : 24/14 u/dl
Chol. Total : 200
mg/dl
HDL : 86 mg/dl
LDL : 113 mg/dl
TG : 71 mg/dl
GDS : 159 mg/dl
Uric acid : 4,2 mg/dl
Echocardiography
49%
Hypokinetic segmental
Diastolic dysfunction LV grade II
Working Diagnosis
STEMI Extensive Anterior
Management
Bed rest
Oxygen 2-4 lpm via nasal canule
IVFD NaCl 0.9% 500 cc/24 hours
Nitrogliserin
DISCUSSION
ST ELEVATION MYOCARDIAL
INFARCTION
DEFINITION
Acute
PATHOPHYSIOLOGY
Occurs when coronary blood
PATHOPHYSIOLOGY
RISK FACTORS
Non-Modifiable
Modifiable
Smoking
Hypertension
Family History
Diabetes Mellitus
Dyslipidemia
Obesity
Lack of physical
father or brother
CAD disease diagnosed before
age 65 in mother or sister
activity
CHANGES IN ECG
DIAGNOSIS
MANAGEMENT
KILLIP CLASSIFICATION
Class
Description
II
17
III
30 - 40
IV
cardiogenic shock or
hypotension (systolic BP < 90
mmHg), and evidence of
peripheral vasoconstriction
60 80
THANK YOU