Acute Coronary Syndrome

(ACS)

dr. Ferdinand Wahyudi

FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIA
RSUD Umbu Rara Meha Waingapu, Sumba timur, NTT
 IDENTITY
Name : HR
Date of Birth : 01 July 1932
Age : 84 y.o
Date of Admission : 01 December 2016
Time of Admission : 01.20 WITA
Address : Desa Tandula Jangga, Kec.Nggaha Ori Angu, Sumba Timur
Religion : Catholic
 PRIMARY SURVEY

Heart Rate Patent, no RR 26 Compos There is no

40 bpm, additional breathes Mentis, wound and
weak pulse, breath per minute, GCS deformity

Breathing
Circulation

Airway

Exposure
Disability
cold sounds SatO2 92% E4V5M6
extremities
 SECONDARY SURVEY
Chief Compliant
Heartburn and vomiting more than 5 times for the last 6 hours

History of Present Illness

6 hours before weak

admission shortness of breath
productive
loss of appetite
cough heartburn and vomiting
began to sweat
burning sensation in his chest
radiated to the throat and around vomitted was yellowish 5
the neck for approximately 30 times
2 days before minutes
admission
 SECONDARY SURVEY
Past Medical History
Patient never checked his health, never hospitalized. A history of hypertension, diabetes,
cholesterol denied.

Drug and Treatment History

No significant drug history

Family History
There is no similar complaints in the family

Social History
Chronic smoker
No history of drinking
 PHYSICAL EXAMINATION
Compos Mentis; GCS 15/15, patients alert and responsive

Vital Sign:
BP: 90/60 mmHg

HR: 40 beat per

minute; regular RR: 26
breathes per
minute
Temp: 36,5oC
 PHYSICAL EXAMINATION
Head Conjungtiva is not pale , Sclera is not jaundice
Neck JVP is in normal range, there was no carotid bruit present
Thorax Inspection:
On inspection, there is no deformity, no dilated vein, no surgical scar, and no
visible pulsation.
Palpation:
The apex beat is not palpable. There was no parasternal heave. Thrills were also
absent.
Auscultation:
S1 and S2 were heard. There was no radiation, no murmur, no rubs and no
additional sounds. S3 and S4 were not heard.
Lung : Ves +/+, Rh +/+, Wh -/-
Abdomen Epigastric tenderness (+), normal bowel sounds, Liver not palpable, spleen not
palpable, ascites not present

Extremitas Edema (-)

Genital Not Available

Kulit No remarkable findings

 DIFFERENTIAL DIAGNOSIS

Community
Inferior STEMI AV Block
Killip I Aquired grade I
Pneumonia
 Done within 10 mins of patient arrival

Findings:
Rate: 52
INVESTIGATIONS - ECG Rhythm: Sinus Rhythm
ST Segment Elevation in II, III and AvF
Prolonged PR Interval
 INVESTIGATIONS
Chest Xray
Cardiac biomarkers
Cardiothoracic ratio increased showing LV Dilatation
Not Available Infiltrate (+)
Sharp costophrenic angles

Hb 14,1g/dL Na 136 mol/L Total Cholesterol Ureum 40 mg/dl

Ht 39,9% K 3,5 mol/L 260 mg/dl Creatinin 0,7 mg/dl
Leu(/mm3 ) 11.100 Cl 101 mol/L LDL 160 mg/dl
Tromb(/mm3 ) 440.000 HDL 40 mg/dl

Complete Electrolite Renal

Blood Count Lipid Profile Function
 MANAGEMENT
Patient was immediately admitted in ICU. Within 10 mins, ECG was performed and
based upon diagnosis, following treatment was given.
Oxygen + Cardiac rhythm monitoring

PROBL 1. Nacl 0,9% loading 1000 mL, mainteneance 40 tpm IVFD

EM
There is no no hospital with a
2. 02 3lpm nc
3. Aspilet clopidogrel loading 4 tab po
PCI facility that can be reached
4. Simvastatin 1x10 mg po
in under 2 hours
5. Inj SA 1 amp IV extra
There is no fibrinolytic agent
6. Inj Metocloperamide 10mg/8 h IV
available
7. Inj Cefotaxim 1gr/12 h IV
Patient refused to be referred
8. Inj Heparin bolus 4000 unit IV, mainteneance 500unit/h sp IV
to a hospital in Bali for
9. Dulcolax 1x10 mg po
economic reasons
10. Alprazolam 1x0,5 mg po
11. Insersi DC Catheter
 FOLLOW UP
WEDNESDAY, 01 DECEMBER 2016

05.30 WITA
Tx : CPR + Bagging
Px apnoe, pulseless,
for 2 minutes, patient was
monitor showed asystol
intubated 05.36 WITA
Tx :
pulseless, no
CPR+Bagging, Inj
05.32 WITA spontaneous breath,
epinephrine 1 amp IV
Tx :Inj epinephrine 1
Asystol
amp IV, CPR+ Bagging

05.56 WITA
05.34 WITA after performed CPR for 20 minutes, monitor
Pulse palpable, spontaneous breath, showed asystol, maximum dilatation of the pupil,
(ROSC) Dolls eye (+), patient was declared dead