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Patient ID
Name
: Mr. P
Age
: 46 years old
Address
: Bulukumba
Medical Record : 386399
Date of Admittance : 30th April 2009
History Taking
Chief Complaint : Chest Pain
History Taking :
Risk Factor
Gender : Male
Dislipidemia (+)
Hypertension (-)
Smoking history (+)
Alcohol (-)
Obesity (+)
Diabetes Mellitus (-)
Physical Examination
General Appearance :
Moderate-illnes/obesity(29,4)/conscious
Vital Sign :
Pulse : 72 bpm
Blood Pressure : 140/90 mmHg
Inspiratory rate : 24 tpm
Body temperature : 36.7 C
Head Examination :
Eyes : no anemia, no jaundice, no cyanosis
Neck : JVP R-2 cmH20
Thoracic Examination :
Inspection : Symmetric sinistra et dextra
Palpation : no mass, no tenderness
Percussion : Sonor
Auscultation : Breath Sound was vesicular, no extra sound
Physical Examination
Cardiac Examination :
Abdominal Examination :
Inspection : Normal
Palpation : no mass palpable, no tenderness
Percussion : tympani
Auscultation : peristaltic sound (+), normal
Extremities :
No limbs oedema
Laboratory Examination
Complete blood
WBC
: 12.6 x 103 /mm3
()
HGB
: 14,6 g/dl
HCT
: 44,3 %
RBC
: 5,31 x 106 /mm3
PLT
: 267 x 103 /mm3
Cardiac enzyme
CK
: 3921()
CK MB
: 563 u/L ()
Blood chemistry
Random blood sugar
: 96
mg/dl
SGOT
: 20 u/l
SGPT
: 9 u/l
Total Cholesterol : 229
mg/dl()
HDL
: 24
mg/dl()
LDL
: 133mg/dl
()
Triglyseride
: 159 mg/dl
Electrocardiogram
Electrocardiogram
Sinus Rhythmic
Heart rate 88 bpm
Axis : LAD
ST Segment : Elevation at L1 V1 V3, V4 V6
Recent anteroseptal lateral Infark Miokard
Echocardiogram
Echocardiogram
Hypokinetic AnteroSeptal
EF 46%
E/A >1
LVH
Conclusion:
Disfunction Sistolic
Suggestion examination
Thorax radiography
Coronary angiography
Diagnosis
Infark Miokard with ST Segment Elevation
Management
Bed rest
Cardiac Diet
O2 4 6 Lpm
IVFD NaCl 0,9 % 12 dpm
Streptokinase 1,5 million unit in a hour
Plavix (clopidrogel) 75 mg 1x1
Aspilet (aspirin) 80 mg 1x1
Isoket (Isosorbit IV) 2mg/ hour
Lovenox (Heparin) 0,6cc/24 hour/ SC
Captopril (ACE inhibitor) 12,5 mg 1-0-1
Simvastatin 20 mg 0-0-2
Alprazolam 0,5 mg 1/2-0-1
Laxadine syr 3 x 1 c
Discussion
ACUTE MYOCARDIAL
INFARCTION
Definition
Myocardial infarction (MI) is the rapid
Pathophysiology
STEMI generally occurs when coronary blood flow
GENDER
HYPERTENSION
DIET
HYPERLIPIDEMIA
SMOKING
FAMILY HISTORY
Clinical features
Presenting complaint :
Diagnose
Signs of myocardial ischemia
ECG
ST segmen elevation ?
No
Lab
No
Yes
Yes
NSTEMI
( No ST-Segment
Elevation
Myocardial Infarction )
Unstable Angina
Electrocardiogram
Classic ECG changes of a full-thickness MI are as follows :
ST segment elevation over area of damage
ST depression in leads opposite infarction
Pathological Q waves
Reduced R waves
Inverted T waves
Management
Bed rest
Diet
Oxygen
Fibrinolytic
Aspirin and/or anti platelet agent
-blocker
Nitrates
Anti Trombolitic
ACE inhibitors
Lipid lowering agent
Surgical care ( PCI or CABG )
Complication to aware
Early : arrhytmias, cardiogenik shock due to heart
failure
Medium term : rupture of papillary muscle,
rupture of interventricular septum, free wall
rupture
Late : cardiac failure, left ventricular aneurysm,etc
Thank you