Case Report

BY :
Juliet C G Umbas (C11108204)
SUPERVISOR :
Prof. Dr. dr. Peter Kabo, Ph.D, Sp.FK, Sp.JP, FIHA

 MR number
:
Name
:
Gender
:
Age
:
Date administered
2013

607725
Mr. E
Male
57 years old
: 27th April

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 doesnt

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 status
Head 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 status
Cardiac Examination
- Inspection : Ictus cordis wasnt visible
- Palpation : Ictus cordis wasnt 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

Gambar x-ray

Conclusion:
Cardiomegaly
with
dilatation of
aorta
Right diaphragm
elevation
(intraabdominal
process suspected)

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

DEFINITION

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

Risk Factor
Modifiable

Non-Modifiable

Smoking

Men, increased risk after age

45

Hypertension

Women, increased risk after

age 55

Diabetes Mellitus

Family history of heart disease

diagnosed before age 55 in
father or brother

Dyslipidemia

Family 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
>/= 3 Risk Factor for CAD

1 point
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

WHO Diagnostic
Criteria
1. Clinical history of ischaemic type
chest pain lasting >20 minutes
2. Changes in serial ECG tracings
3. Rise and fall of serum cardiac
biomarkers such as Creatinine
Kinase-MB fraction and troponin

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 armsfrequently on
left.
Associated features : Not relieve with
rest or nitrat


o
o
o
o
o
o
o

o
o
o

Fixing the chest pain and fearness

Bed rest
Diet
O2 2-4 lpm
Nitrate sublingual/oral/IV
Antiplatelet : aspirin and clopidogrel
Morfin/petidine
Diazepam 2-5mg/8 hour
Stabilizing the hemodynamic ( blood pressure and
pheripheral pulse control)
-blocker
Calcium chanel blocker (CCB)
ACE-Inhibitor
Reperfusion of the myocard
Thrombolitic

PROGNOSIS
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

III

acute pulmonary edema

30 - 40

IV

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

60 80

17