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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 : 36,7˚C
 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
 Heart’s 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