Advisor : dr. H. M. Saugi Abduh, Sp.

PD, KKV, FINASIM

 Name : Mrs. M
 Age : 52 years old
 Sex : Female
 Job :-
 Religion : Moslem
 Status : PBI
 No. RM : 01292475
 Room : Baitul Izzah 1
 Entry Date : August 5st 2016
 Exit Date : August 12th 2016
 Main Complaint : Chest pain

History of Present Illness

Patient came to the hospital and complained chest pain
in the midle. Its started at 4 August 2016 after she clean
her home. The chest pain occurred more than half an hour.
The characteristic of this pain like a pressed in her chest
and spread until her back, neck and left shoulder. She feel
the pain lost and found, the pain often come and
worsening when do an activity and become better after
took a rest. And the other complained are she feel
weakness.
 History of Same Illness (-)
 Hypertension History (+)
 DM History (-)
 Heart Dissease History (-)
 Smoking (-)
 Alcohol Use (-)

No family has the same illness

Hypertension history (+)
DM history (-)
Asthma history (-)

 The medication fee guaranteed by “PBI”

Chief Complains : Chest pain
Onset : 1 days ago
Location : Substernal
Chronology : Patient complained about chest
pain and it started at 4 August 2016 after she clean her home.
Quality and Quantity : The chest pain occurred more than
half an hour. The characteristic of this pain like a pressed in
her chest and spread until her back, neck and left shoulder.
Modification factor : The pain often come and
worsening when do an activity and become better after took
a rest.
Comorbid complains :Weakness.
 General : Compos mentis
 Skin : Itch (-), Wound (-), Jaundice (-), Pale (+)
 Head : Dizziness (-)
 Eyes : Red eye (-), anemic conjunctiva (-), jaundice
sklera (-)
 Ears : Hearing loss (-), ringing (-), discharge (-)
 Nose : Epistaxis (-), Discharge (-)
 Mouth : Sianosis (-), Sprue (-), Bleeding gums (-)
 Troat : Sore troat (-), Hoarseness (-), Disfagia (-)
 Neck : Swelling (-), neck stiffness (-),
 Chest : Chest pain (+), palpitation (-)
 GIT : Appetite (-), Nausea (-), vomit (-), hematemesis (-),
defecation abnormality (-), abdominal pain (-)
 Urogenital : dysuri (-), hematuri (-), tea colour of urination (-)
 Musculoskeletal : parestesia (-), Low Back Pain (-)
 Extremity : oedem (-/-), parestesia (-/-), wound (-/-)
 Vital Sign
Patient Status
• BP : 148/95 mmHg
• Age : 52 years old • HR : 96 x/m
• Sex : Female • RR : 20 x/m
•T : 36 C

Nutrient Status Hypertension grade 1

•Waist circumference : 83 cm
• weight : 78 kg
• Height : 166 cm
•BMI = 78
(1,66)2 = 28,36
Overweight
 Head : Mesocephal, alopesia (-)
 Eyes : Anemic Conjuntiva(-/-),Icteric sclera(-/-)
 Nose : symmetric, secret (-), Nostril Breath (-)
 Ears : Normal Shape, discharge (-/-)
 Esophagus : Hyperemic (-), pain devour (-)
 Mouth : Cyanosis (-), dry lips (-),
 Neck : Trakhea deviation (-), Lymph Hypertropy (-)
 Extremity : Oedem of lower extremity / upper extremity (-) / (-)

Intepretation : Normal
Inspection : Ictus cordis isn’t seen
Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-),
sternal lift (-)

Percussion : dull sound

 Upper borderline of heart : ICS II left sternal line
 Waist of heart : ICS III left parastern line
 Lower right borderline of heart : ICS V right sternal line
 Lower left borderline of heart : ICS V, 2 cm lateral from left
mid clavicle line

Auscultation
 Aortal valve : S1 & S2 standard, additional sound (-)
 Pulmonary valve: S1 & S2 standard, additional sound (-)
 Tricuspid valve : S1 & S2 standard, additional sound (-)
 Mitral valve : S1 & S2 standard, additional sound (-)

Intepretation : NORMAL
 INSPEKSI ANTERIOR POSTERIOR

Static RR : 24x/min, Hyper pigment (-), RR : 24x/min, Hyper pigment

spider nevi (-),spider nevi (-), Hemithoraks D=S,
(-), atrophy Pectoral Muscle (-), ICS Normal, Diameter AP < LL
Hemithoraks D=S, ICS Normal,
Diameter AP < LL

Dynamic Up and down of hemitoraks D=S, Up and down of hemitoraks D=S,

abdominothorakal breathing, (-), abdominothorakal breathing (-),
muscle retraction of breathing (-), muscle retraction of breathing(-),
retraction ICS (-) retraction ICS (-)

Palpation Palpable pain(-), tumor (-), Arcus Palpable pain (-), tumor (-), Arcus
costae angle < 900, enlargement of costae angle < 900, enlargement of
ICS (-), Stem fremitus D=S ICS (-), Stem fremitus D=S
Percution Sonor Sonor

Auskultatio Vesicular (+), Whezzing (-), Ronchi (-) Vesicular (+), Whezzing (-),
Intepretation :
n NORMAL Ronchi (-)
 Inspection : symetric, sycatric(-), striae(-),enlargement of
vena (-), caputmedusa (-).
 Auscultation : peristaltic (+)
 Palpation
Superfisial : tight (-), mass (-), epigastrial pain (-)
Deep : abdominal pain (-), liver, kidney, and spleen
weren’t palpable, Murphy’s sign (-)
 Percussion : tympani, side of deaf (-), shifting dullness (-)
• Liver : deaf(+), right liver span 11 cm, left liver span
6 cm
• Spleen : Throbe space percussion (+)  tympani

Intepretation : NORMAL
 Superior Inferior
Oedem -/- -/-

Pitting Oedema -/- -/-

Cyanotic -/- -/-

Cold Extremity -/- -/-

Capillary Refille -/- -/-

Clubbing Finger -/- -/-

Laboratory Examination Results Normal Value
Hb 13,7 11,7-15,5 g/dL
Ht 41,3 33 – 45 %
Leucocyte 11,0 3,6 – 11,0 ribu/uL
Trombocyte 344 150 – 440 ribu/uL
Golongan Darah A / Rh +
 Results Normal Value
Cholesterol 285 < 200 mg/dL
Trigliserida 211 < 160 mg/dL
HDL 50 37-92 mg/dL
LDL 198 60 – 130 mg/dL Intepretation :
Uric Acid 4,4 3,5 - 7,2 mg/dL Hipercholesterol
GDS 108 75 – 110 mg/dL Hipertrigliserida
Natrium 142,9 35-147 mmol/L
↑LDL
Elevation of
Kalium 4,00 3,5-5 mmol/L
cardiac marker
Chloride 105 95-105 mmol/L
Calcium 10,1 8,8-10,8 mmol/L
Magnesium 2,0 1,6-2,4 mg/dL
Ureum 20 10 – 50
Creatinin 0,64 0,5 – 0,9
Troponin I Ultra 2,47 <0,01 ug/L
 5/8/2016

 IRAMA : Sinus rhytm

 REGULARITAS : Regular
 FREKUENSI : 1500/15 = 100x/menit
 AXIS : NAD
 GELOMBANG P : 2 x 0,04 = 0,08 s
 PR INTERVAL : 4 x 0,04 = 0,16 s
 QRS COMPLEX : 0,08 s
 ST SEGMEN : ST elevation (V1,V2,V3)
 GELOMBANG T : T inverted (I, AVL, V1, V2, V3, V4, V5, V6)
 ZONA TRANSISI: V4
 CONCLUSION : STEAMI (anteroseptal infarction)
 6/8/2016

 IRAMA : Sinus rhytm

 REGULARITAS : Regular
 FREKUENSI : 1500/18 = 83x/menit
 AXIS : NAD
 GELOMBANG P : 2 x 0,04 = 0,08 s
 PR INTERVAL : 4 x 0,04 = 0,16 s
 QRS COMPLEX : 0,08 s
 ST SEGMEN : ST elevation (V1,V2,V3)
 GELOMBANG T : T inverted (I, AVL, V1, V2, V3, V4, V5, V6)
 ZONA TRANSISI: V4
 CONCLUSION : STEAMI (anteroseptal infarction)
 8/8/2016

 IRAMA : Sinus rhytm

 REGULARITAS : Regular
 FREKUENSI : 1500/18 = 83x/menit
 AXIS : NAD
 GELOMBANG P : 2 x 0,04 = 0,08 s
 PR INTERVAL : 4 x 0,04 = 0,16 s
 QRS COMPLEX : 0,08 s
 ST SEGMEN : ST elevation (V1,V2,V3)
 GELOMBANG T : T inverted (I, AVL, V1, V2, V3, V4)
 ZONA TRANSISI : V4
 CONCLUSION : STEAMI (anteroseptal infarction)
 10/8/2016

 IRAMA : Sinus rhytm

 REGULARITAS : Regular
 FREKUENSI : 1500/18 = 83x/menit
 AXIS : NAD
 GELOMBANG P : 2 x 0,04 = 0,08 s
 PR INTERVAL : 4 x 0,04 = 0,16 s
 QRS COMPLEX : 0,08 s
 ST SEGMEN : ST elevation (V1,V2,V3)
 GELOMBANG T : T inverted (I, AVL, V1, V2, V3, V4, V5)
 ZONA TRANSISI: V4
 CONCLUSION : STEAMI (anteroseptal infarction)

 COR : CTR <50%
 Pulmo : Corakan
bronkovaskuler
normal
 Tak tampak bercak
pada kedua paru
 Diafragma dan sinus
kostofrenikus baik

KESAN
 COR : Tak Membesar

 Pulmo : Tak tampak

kelainan
 RCA
Stenosis 80% di mid
 LAD
Total oklusi di proksimal
mid
 LCX
Stenosis 30% di distal

 Kesimpulan
CAD 2 VD
 Lab Hematology ECHO

History Taking 6. Hipercholesterol 12. Hipokinetik

1. Chest pain 7. Hipertrigliserida segmental

2. Weakness 8. ↑ LDL 13. Disfungsi LV

9. Cardiac marker diastolik
elevate
Angiografi
Physical ECG :
14. RCA
Examination 10. ST elevasi (Stenosis 80% mid)
15. LAD
4. High blood V1,2,3
(Total oklusi
preasure : 148/95 11. T inverted proksimal mid)
16. LCX
5. BMI = 28,36 (I,AVL,V1,V2,V3,
(Stenosis 30% distal)
V4,V5,V6)
1. SKA (1,2,9,10,11,12,13,14,15,16)
2. Dislipidemia (6,7,8)
3. Hypertension grade 1 (4)
3. Overweight (5)
Troponin CK-MB
Troponins are highly cardiospecific Low cardiospecific
(100%).

High specificity Low specificity

Sensitivity for micro, early, Sensitivity for micro, early,
advanced AMI (+) advanced AMI (-)
Compared with CK-MB measurement, troponin assays are substantially
more sensitive in the detection of myocardial injury.

Studies have shown that cardiac troponins should replace CKMB as the
diagnositic ‘gold standard’ for the diagnosis of myocardial injury.
 Ass: STEMI  Pharmacology

 IP Dx : - ISDN subl. 5 mg 3x1 prn

 IP Tx : Aspillet 80 mg 1x1

 Non Pharmacology CPG 75 mg 1x1

 O2 nasal canul Atrovastatin 20 mg 1x1

4L/minute Heparin
 Low Fat Intake

 Reduce activity
Ip. Mx : Vital sign, ECG serial, APTT

Ip. EX :

 Bed Rest/Restriction of physical activity

 Reduce fatty food

 Reducing Emotional stress

 Control blood pressure

 Routine consumption drugs

 Avoid smoking
 Ass :
Risk factor : DM, Dislipidemia, smoker, obesity, alcholol use history.
 Ip Dx :
Profil lipid, GDS
 IpTx :
 Non Pharmacology :
 Low salt intake
 Pharmacology :
 Bisoprolol 2,5 mg 1x1
 Captopril 12,5 mg 3x1
 IpMx :
 Vital Sign, electrolit
 IpEx :
 Diet low salt
 Stay away from stress
 Increase mild exercise
 Routine consumption drugs
 Routine check of blood pressure
 Ass: -

 IP Dx : -

 IP Tx :

• Pharmacology :

• Atorvastatin 20 mg 0-0-1

• Non pharmacology

• Daily dietary consumption of fruits and vegetables

• Exercise 60 minutes with aerobic and resistance training

• Achieve ideal body mass index and body weight

 Ip.Mx : total cholesterol, HDL, LDL, trigliserid

 Ip.Ex :

• Eat high fiber diet and low fat

• Reduce fatty food, soda and junk food

• Exercise regularly
 Ass : -
 Ip Dx : -

 Ip Tx :

 Non Farmakologis

 Hitung kalori (1276 x 1,2 = 1532 kal )

 General advice on healthy weight and life style
Ip Mx :
 Monitoring weight
 Waist circumference
Ip Ex :
 Diet Low Calori
 Diet Low Fat
BMR = 447,593 + (9,247x (166-100)) + (3,098x166) – (5,677x52) =
1276,956
Kalori harian = 1276,956 x 1,2
= 1532 kal
 Skor : 122

 Untuk prediksi kematian di rumah sakit

skor risiko GRACE ≤108 : risiko rendah (risiko kematian <1%)
skor risiko GRACE 109-140 : risiko kematian menengah (1-3%)
skor resiko GRACE >140 : risiko kematian tinggi (>3%)

 Untuk prediksi kematian dalam 6 bulan setelah keluar dari rumah

sakit
skor risiko GRACE ≤88 : risiko rendah (risiko kematian <3%)
skor risiko GRACE 89-118 : risiko kematian menengah (3-8%)
skor risiko GRACE >118 : risiko kematian tinggi (>8%)