CASE REPORT STEMI LATERAL

By : Cut Rully Marvita Supervisor : Dr. Nurkhalis, Sp. JP FIHA

Identity
Nama Age Gender Religion Ethnic Occupation Address Addmision Examination date : Mr. Z : 54 years old : Male : Islam : Aceh : Mechanic : Lampulo : January 3rd 2013 : January 6th 2013

The Main Cause

Chest Pain

History of Present Illness

patients present with complaints of chest pain that is felt spreading to the left arm and lower jaw. Chest pain is also felt through to the back of the body. Patients may also experience bloating which suppresses the chest and stomach. This complaint is felt 4 hours before admission to the hospital. The patient also complained of shortness of breath at the time of chest pain.

History of previous illness A year ago, the patient had been treated with the similar complaint History of drug use Data treatment for patients admitted to have been lost. Previously, patients taking medications that are given from the hospital, the patient no longer taking medication when the patient felt himself cured. History of family disease His mother had hypertension History of patients social customs Patients smoked since the age of 10 years, for 30 years the patient smoked about 2 packs of cigarettes a day

Unmodified Risk Factors

Modified

Risk Factor

Male

Smoking Cigarettes

age above 40 years

Status Present General Condition : Moderate Consciousness : Compos Mentis Blood Pressure : 110/70 mmHg Heart Rate : 80x/menit, reguler Respiratory Rate : 24x/menit Temperature : 36,60C Status General Skin Colour : Brown Turgor : quick return Ikterus : (-) Anemia : (-) Sianosis : (-) Oedema : (-) Head Shape : Normocepali Hair : Black Eyes : Light Reflection (+/+), Pale inf. Palpebra Conjungtiva (-/-)

Leher TVJ swollen lymph nodes Thorax Inspection Shape and Motion Respiration Type Retraction Palpation Strem femitus Percussion Auskultation

: R2 cmH2O : negative

: Normochest, Symetric movement : Thorako-abdominal : (-)

: Same in both part of the lung : Same in both part of the lung : Ves (+/+), additional sound (-)

COR Inspection Palpation Percussion

Auscultation ABDOMEN

: Ictus Cordis not visible : Ictus Cordis perceived on ICS V LMCS. : Heart barier Top : on ICS III Right : on ICS V LPSD Left : on ICS V LMCS : BJ I>BJ II, reguler, noisy (-)

Inspection Palpation

: Symmetric, Distensi (-) : Soepel (+), Nyeri tekan (-) Hepar dan ginjal tidak teraba Percussion : Tympani (+), Asites (-) Auscultation : Peristaltik usus (N) Extermitas edema : (-)

Laboratory Results ( January 4th 2013 )

Examination Hb Leukosit Trombosit LED Hematokrit Ct Bt Total bilirubin Bilirubin direct Bilirubin indirect SGOT SGPT Alkali phospatase albumin Result 13,5 15,7 189 6 36 9 3 0,78 0,68 346 32 130 4,0 Globulin Ureum Creatinin GDN Total cholesterol Trigliserida Asam Urat HbsAg Result 2,6 25 0,8 101 285 102 2,9 Negative

Electrocardiografi (Januari 3rd 2013)

ECG Interpretation

Rhtm Heart Rate Axis Interval PR Regularitas P wave QRS Complex LVH RVH ST elevasi dan V6 ST depresi Q patologis V4 T inverted VES Interpretasi Kesan

: Sinus : 86x/ menit, regular : normoaxis : 0,16 sec : reguler : 0,08 detik : 0,10 detik ::: Lead I, II, AVL, V1, V5 :: III, AVF, V2, V3 dan ::: STEMI Lateral : Abnormal EKG

Thorak x-ray (January 3rd 2013)

X-ray Interpretation Cor :enlarged by 55% CTR, no hypertension configuration overview costophrenicus and cardiophrenicus both are sharp. Pulmo : cephalisasi (+), Infiltration (-) Conclusion : Kardiomegali and Oedem pulmonal

Diagnosis

STEMI Lateral onset > 3 jam Killip I TIMI RISK 4/14 GRACE skor 152

Treatment
Spesific
General
IVFD RL 10 gtt/i Drip Streptase 1500000 IU in 1 hr Lovenox 0,6cc/12hr Aspilet 320 mg (loading dose) Maintanance dose: 1x80mg CPG 300 mg (loading dose) Maintanance dose: 1x75mg Simvastatin 1x 20mg Drip Cedocard mulai 5 meq/kgbb/hr Sucralfat syr 1xCI Laxadin Syr 3xCI

Bed rest Heart diet1600 kkal/day

Diagnostic Planning
Serial ECG Complete blood laboratory test CKMB test Corangiography

Prognosis
Quo ad Vitam Quo ad Functionam Quo ad Sanactionam

: Dubia ad bonam : Dubia ad malam : Dubia ad malam

SINDROMA KORONER AKUT

Without ST elevation (UAP / Non STEMI)

With ST elevation (STEMI)

Miocard Infarction in pathology as myocardial cell death due to prolonged ischemia.

Different stages of atherosclerotic plaque development

Clinical Manifestation
Chest pain lasting for 2o min or more, not

responding to nytroglicerine. Important clue are a history of CAD and radiation of the pain to the neck, lower jaw or left arm. ST segment elevation in acute myocardial infarction should be found in two countiguous lead and be 0,25 mV Biomarker test such as troponin and CKMB

Admision
Diagnosis Kerja ECG Biochemistry

Chest Pain Acute Coronary Syndrome Persistent ST Elevation ST/Tabnormalities Normal atau Tdk dpt ditentukan ECG

Troponin rise/fall

Troponin normal

Diagnosis Pengobatan

STEMI
Reperfusi

NSTEMI
Invasive

Angina tidak stabil

Non-Invasive ESC 2007

Fibrinolitik / PCI

STEMI Diagnosis

Primary PCI Capable Center

EMS or Non Primary PCI Capable Center

Preferably < 60 min

PCI Possible < 120 min?

Primary PCI
Rescue PCI

YES Preferably 90 min ( 60 min in early presenters

NO

NO

YES
Preferably 3-24h

Successfull FIbrinolysis

Immediate Fibrynolysis

Coronary Angiography

Treatment
Reperfusion therapy - PCI (Percutaneus Chateter Intervention) - Pharmacotherapy

(Aspirin and ADP) Fibrinolisys Long term therapy Aspirin Beta blocker Lipid lowering therapy Nitrates Calcium antagonist ACE Inhibitor Aldosteron antagonist

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