INTAN EKARULITA

MELISA AYU
Name : Mr. D U

Address : Jalan Adan RT 6/11, Rawa
Belong, Jakarta Barat

Date of Birth : 04
th
of July 1968

Age : 46 years old
Chief Complaint :
Chest pain since 6 hours before he came to
hospital

Additional Complaints :
Shortness of breath
Dizziness



Patient came with chest pain since 6 hours
before he came to the hospital.
The pain felt all over his chest area.
It happened suddenly after he got cough.
The pain felt like his chest pressed which
worsens while he was walking.
It felt continuously and did not radiate to any
other parts of his body.
Shortness of breath
It felt at the same time with his chest pain.
It was getting better when he was lying down and
getting worse when he was walking.
Dizziness
It was the first time he felt this symptoms
He used one pillow while lying down.
Palpitation (-), abdominal discomfort (-)
The patient is a smoker since 25 years ago.
10 cigarettes per day
Taking drugs (-)
Heart disease (-)
Diabetes Mellitus (-)
High Cholesterol (-)
Hypertension (+)
Since 2 years ago
Did not take any medicine
General State : Appeared severely ill
Awareness : Compos Mentis
Vital Signs :
BP : 130/80 mmHg
HR : 83 x/minute
RR : 20 x/minute
Temp : 36,7C
Head : normocephal

Eyes : anemic conjunctiva -/-, icteric sclera -
/-, palpebral edema -/-, pupil isokor, light
reflexes +/+

ENT : nostril breath (-), secrete (-),
hyperemic pharynx (-), tonsils T2-T2

Neck : impalpable lymph node, JVP
5+2cmH
2
0
Thorax : normochest, discoloration (-)
Lungs :
hemithorax moved symmetrically, retraction (-)
vocal fremitus : symmetric
Sonor in all area of the thorax
Vesicular breath sound, wheezing (-/-), rhonki(-/-)

Heart :
Ictus cordis : invisible, palpable at ICS V midclavicular
line sinistra
Hearts borderline
Right : ICS V parasternal dextra
Apex : ICS V midclavicular sinistra
Superior : ICS II parasternal sinistra
S I&II regular, murmur (-), gallop (-)


Abdomen
Supel, spider naevi (-), scar (-), caput medusa (-)
Distention (-), skin turgor : normal, pain on
palpation (-), massa (-), hepar and spleen : normal
Tymphanic sound on all area of abdomen
Peristaltic (+), normal
Extremities
Warm on all four extremities
No edema on all extremities
No clubbing fingers
ECG
Roentgen Thorax
Laboratory Test : CKMB, troponin I dan T,
HDL, LDL, TG, Cholesterol Total, and Random
Blood Glucose.
LAB RESULTS
Hb 14.5
Ht 44%
Eri 5.9
Leukocytes 13400
Thrombocytes 373000
CPK 1012
CKMB 166
Ureum 45
Kreatinin 1.7
GDS 147
Na/K/Cl 138/4.4/102
ST Elevation in lead I
ST Depression in lead III

ST Elevation in Lead I, aVL, V6
ST Elevation Myocard Infarct
O2 in nasal cannule
CPG 4 x 75 mg
Aspirin 1 x 160 mg
Simvastatin 1 x 20 mg
ISDN 1 x 5 mg sublingual
Streptokinase 1.5 millions Unit in 1000 NaCl
drips in 60 minutes

Anamesis sudah menunjukan gejala typical
angina
Foto rontgen seharusnya tetap dilakukan
untuk mengetahui adanya hipertrophy
jantung untuk menentukan KIPI score sebagai
prognosis
Menentukan TIMI score
Pengobatan terbaik seharusnya PCI namun
tidak dilakukan di IGD