Case Presentation

By :
Aulia Agung G99131022
Dwi Tiara S G99131035
Agrensa R S G99131070
Henrikus Jeffry L G99131040
Luqma Prinata G99131050
KB. Dinda SM G99131046

Advisor :
Prof. Dr. dr. Mochammad Fathoni, SpJP(K), FIHA, DAsCC, FAPSC
Patient Identity
 Name : Mr. W
 Age : 55 years old
 Sex : Male
 Address : Surakarta
 Job : Civil Servants
 Date of entry : 12 June 2014
 Date of inspection : 12 June 2014
 Medical Record Numb. : 01-25-81-67
Anamnessis

Chief CHEST
Complain : PAIN
History of Present Illness:
Patient is referred from dr Oen hospital with STEMI inferior.
Has ben given therapy such as ranitidine injection 1 amp,
ascardia 160 mg, and 300mg plavix

Chest pain that patient complained since 10 hours before

entering the hospital. The pain felt like being pressed by heavy
object and spreading to left arm and neck. The pain usually felt
when resting. The duration of pain was more than 20 minutes.
Patient sleeps with 1 pillow. The other complains was shortness
of breathing and palpitations

The chest pain shows up after a moderate activity such as

walking 100 meters or when climb on the 2nd stairs 1 week
before entering the hospital. The pain relieved with resting and
the duration of the pain was less than 5 minutes
Risk Factor :
 History of hypertension : (-)
 History of diabetes mellitus : (-)
 History of dyslipidemia : unknown
 History of smoking : (+) 2 packs per days
 Family history : (-)

History of Past Illness :

 History of heart disease : (-)
 History of stroke : (-)
Physical Examination :
General Condition : Looked moderately ill

Awareness : CM RR : 20 x /minute Body Hight : 160 cm

Blood Pressure : 60/palpation Temp : 36.5OC SpO2: 98.9%
HR/Pulse : 51/51 x/ minute Nutrient : enough Body Weight : 70 kg

Head Pale conjungtiva(-/-), icteric sclera (-/-) moon face (-)

Neck JVP 5 + 2, buffalo hump (-)

Thorax Symmetrical in static and dynamic movement, lung liver boundary in the SIC V

Cor ictus cordis was not visible,ictus cordis was palpable at fifth intercostal at the left midclavicle, right
heart border on fifth intercostal at right sternal line, left heart border on fifth intercostal at the left
midclavicle, heart waist third intercostal at left parasternal line, S I-II Normal, murmur (-), gallop (-
)
Pulmo right fremitus = left fremitus, sonor, vesicular breath sound (+/+), ronchi (-/-)
, wheezing (-)
Abdomen Hepar, lien was not palpable, Bowel sound (+) normal. Ballotement (-)

Ekstremitas cianosis-/-, oedema -/-, clubbing-/- Motorik 5-5

-/- 5-5
 ECG : Total AV Block, HR : 49 x/m, axis : normoaxis, P wave
0,04 s, variated PR interval, QRS comp : 0,06 s, Q patology lead
III, AVF, Elevated ST segment lead III, AVF, ST depression lead
V1-V4, T inverted (-), V1+R V5 <35 mm. U wave (-), QT interval :
0,44.
 Diagnosis ECG : Bradicardi sinus, HR : 49 x/m, axis : normoaxis,
STEMI Inferior + suspect Posterior
Post Strepto
 ECG post Streptase (an hour) : Sinus Rhytm, HR : 78
x/m, axis : normoaxis, P wave 0,04 s, variated PR
interval, QRS comp : 0,06 s, Q patology lead III, AVF,
Elevated ST segment lead II, III, AVF, ST depression
lead V2-V4, T inverted (-), V1+R V5 <35 mm. U wave (-
), QT interval : 0,44 s, PAC Occational.
 Diagnosis ECG : Sinus Rhytm, HR : 78 x/m, axis :
normoaxis, STEMI Inferiot + Posterior + RV, PAC
Occational.
Laboratorium :
Hb 14.4 Ur 41 BJ -
AL 16.5 Cr 1.2 PH -

HCT 42 Na 138 Nitrit -

AT 292 K 3.6 Protein -

AE 5.13 Cl 107 Glucose -

MCH 28.1 Albumin - Keton

MCHC 34.4 Glucose 304 Urobilinogen -

MCV 81.7 SGOT 382 Bilirubin -

AGD SGPT 210 Eritrosit -

PH - Leukosit -

PCO2 - PT -

PO2 - APTT - HbsAg Non Reactive

HCO3 - INR -

TCO2 -

BE - Trop I 8.63

Si O2 - CKMB 171.0

Present: increase of cardiac marker, azotemia, hyperglikemia, increase ofenzym tramnsaminase

Radiology :
 Rontgenof Thorax AP(less
inspiration) : CTR 54%,
Aortic elongationand
dilatation (-) , Perihiler haze
(-), apex grounded, blunting
of left and right costophrenic
angle (-), trachea in
midline,normalbone system
 Conclusion : Cardiomegaly
Diagnose :
 A (x) :STEMI Inferior + Posterior + RV
 F (x): Killip IV
 E (x) : Coronary heart disease
 Risk factor : male, smoker
 TIMI Score : 8/14, The 30 days mortality 5.8%
 Grace Score : 160, In Hospital Death 23 %
Therapy in ER :

O2 3 lpm nasal
Totalbedrest
canule

Inf RL 500 ml fast

Aspilet 160 mg
loading  TD :
loading
80/60 mmHg
Therapy :

Total bedrest DJ 1700 kkal O2 3 lpm nasal canul

Inf RL 500 ml fast

Inj Streptase
loading  TD : 98/43
1.500.000 unit inNaCl InjArixtra 2.5 mg/24
mmHg, Loading RL
0.9% 100 ml (30-60 hour IV
300 ml  118/54
minute)
mmHg

Aspilet 1x80 mg Clopidogrel 1x75 mg Simvastatin 1x20 mg

Planing :
• Echocardiography

• Complete laboratory check

• Consult to Internist
Case Analysis
The patient was a man, 55 years old who is a referral from
Dr. Oen hospital with a diagnosis of STEMI Inferior. He
have Got therapy Ranitidine inj 1 amp, Ascardia 160 mg,
300 mg Plavix. He is referred to RSDM because ICU in Dr
oen was full.

Patients present with chest pain since 10 hours

before coming to the hospital. Chest pain is felt as
crushed heavy objects, radiating to the left arm and
neck. Chest pain is felt when the patient is lying
down resting. Pain is felt with a duration of> 20
minutes. Patients sleep with 1 pillow. Complaints
chest pounding denied. Shortness of breath (+),
PND (-), DOE (-), orthopneu (-), fever (-),
palpitations (-).

•
•
Blood pressure in 60/palpasi
Pulse 51 x / minute,
• HR 51 x / min,
• RR 20x/menit, and the
• Temperature of 36.5 º CA
Vital Sign
• laboratory tests of blood
found increasing of cardiac
marker and enzim
General tramnsaminase, azotemia,
hiperglikemia
Status • Radiology : Cardiomegaly
>54%
• EKG obtained at a total AV
• CM, Look weak block HR 49 x/ ', normoaxis,
• Shortness of breath STEMI Posterior + Inferior +
• nutritional status is enough RV, Occasional PAC
• skin is not visible cyanosis
• both eyes do not look conjunctival
anemic
• JVP not increased
Additional
•chest wall retraction is not obtained
• heart sounds S1 and S2 normal
intensity and did not reveal any examination
abnormal heart murmur
• Vesicular basis sound in both lung
fields normal
 Patients feel chest pain caused by damage (necrosis)
of heart muscle due to blood flow to the heart muscle is
interrupted. As a result, there was myocardial ischemia. A
decrease in cardiac perfusion resulting in a decrease in the
intake of oxygen and the accumulation of products of
metabolism of chemical compounds. The accumulation of
these metabolites arise because of inadequate oxygen
supply, the myocardial cells compensate by respiring
anaerobically. As by-products of lactic acid. Lactic acid
makes the cell pH decreases. Changes in myocardial
metabolism of these cells are stimulated via the
sympathetic afferent pain receptors in the primary sensory
cortex area (area 3,2,1 Broadman) which causes pain in the
chest.
 Patients feel shortness of breath caused by the
damming is occurring in the lungs. This is caused by
the failure of the left ventricle pumps blood
throughout the body, thus resulting in the volume of
blood remaining in the ventricle. The volume of blood
left in the ventricle causes an increase in pressure in
the left atrium. Resulting in increased retrograde
pressure. With the increased pressure in the
pulmonary veins of more than 20mmHg there will be a
transudation of fluid into the lungs out. This is what
causes patients to feel short of breath.
 When the pressure in the pulmonary artery and
bronchial rises also occurred in the interstitial tissue
transudation bronchi, the tissue becomes edema and
this will reduce the size of the bronchial lumen, so the
airflow becomes disturbed. In these situation it
breathing sounds is reads during expiration, expiratory
murmur and expiratory phase becomes longer, this
situation is known as cardiac asthma.
Increased pressure in the alveolar capillaries
resulting in transudation of fluid in the interstitial
tissue and alveoli that found the presence of the sound
wet smooth crackles and coarse wet crackles.