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CASE REPORT

ACS Lateral Non ST-Elevation


Myocardial Infarction (NSTEMI)
CARDIOLOGY DEPARTMENT
Faculty of Medicine, Tanjungpura University
Dustira Hospital, Cimahi

Supervisor : Prihati Pujowaskito, dr., Sp.JP(K), MMRS


By : Chandra, S.Ked
Nim : I11112028
PATIENT IDENTITY
• Name : Mr.H
• Sex : Male
• Age : 58 years old
• Address : Babakan Rahayu
• Admission date : December 20th, 2017
CHIEF COMPLAINT

Chest pain
HISTORY OF PRESENT ILLNESS
• Chest pain that described as a "pressure" and discomfort in the chest
especially on the left side
• Since 3 hours before admission to EMS
• The pain radiates to his left shoulder
• The pain duration is about 10 minutes
• The complaint is sometimes accompanied by cold sweating, nausea,
and shortness of breath
HISTORY OF PAST ILLNESS
• History of Hypertension, Diabetes Mellitus and Tobacco use
• No history of Hypercholesterolemia and heart disease

FAMILY HISTORY
• No family history of hypertension and heart disease
PERSONAL AND SOCIAL HISTORY

Patient was an active smoker for the last 25 years and


have been stop 1 month.
PHYSICAL EXAMINATION
• Head : Normocephal
• Compos Mentis • Eye, Ear, Nose, Throat, and Neck
• SpO2 : 98% • Eye : Conjunctiva anemic (-), sclera icteric (-)
• Ear : Normotia/normotia, secret -/-
• Vital Sign • Nose : Cavum nasi clear/clear, secret -/-
• BP : 130/90 mmHg • Throat : Pharynx hyperemic (-)
• Neck : JVP normal, lymph node swelling (-)
• HR : 115 bpm, regular,
pulsus deficits (-) • Pulmo : Vesicular (+/+), wheezing (-/-),
rhonki (-/-)
• RR : 24 bmp
• T : 36,7 °C • Cor : Regular S1/S2, murmur (-), gallop (-)
• Abdomen : Bowel sounds (+), soepel,
tenderness (-)
• Extermities : edema (-/-), CRT <2s
ELECTROCARDIOGRAM

Interpretation
HR : 115 bpm
Rhythm : Sinus
Axis : Normoaxis
QRS complexes : 0,12 ms
ST segment : ST-depretion lead
V4, V5 and V6

Conclusion
Lateral NSTEMI
LABORATORY FINDINGS
Hb 15,8 g/dl
Eritrosit 5,1 106/uL • Random glucose level : 156 mg/dL
Leukosit 9,5 103/uL • Creatinine : 1,3 mg/dL
Hematokrit 43,4 %
• CK-MB : 17 U/L
Trombosit 270 103/uL
• Troponin I : 1,16 ng/ml
INITIAL DIAGNOSIS
• Clinical diagnosis :
Acute Coronary Syndrome Non ST-Elevation
Myocardial Infarction
• Anatomical diagnosis :
Lateral Myocardial Infaction
• Etiological diagnosis :
Atherosclerotic
GRACE SCORE
Risk Inhospital Mortality 6 Month post discharge
Category with NSTEMI mortality NSTEMI
Grace Probability of Grace Score Probability of
Score Mortality (%) Mortality (%)
Low 1 – 88 <3 27 - 99 < 4.4
Intermedi 89 – 118 3–8 100 – 127 4.5 – 11
ate
High 119 -  8 128 -263 > 11
263
36

23
14
11
7
15

106
MANAGEMENT
In Emergency Departement:
Non Farmacology
• Bed Rest
• Risk factors control
• O2 via nasal canule 2-3 lpm (If SpO2 < 90%)
Farmacology
• IVFD RL 500 cc/ 24 hours
• Drip Nitrogliserin 20 mcg/minutes
• PO Loading CPG 300 mg (4 tab)
• PO Loading aspirin 160 mg (2 tab)
• PO Ramipril 1 x 5 mg
• PO Atorvastatin 0-0-20 mg
• Inj. Arixtra (Fondaparinux) 1 x 2,5 mg SC
MANAGEMENT
Reperfusion Management
Non Farmacology
• Bed Rest
• Risk factors control
• O2 via nasal canule 2-3 lpm (If SpO2 < 90%)
Farmacology
• IVFD RL 500 cc/ 24 hours
• Inj. Arixtra (Fondaparinux) 1 x 2,5 mg SC
• PO Aspirin 1 x 80 mg
• PO CPG 1 x 75 mg
• PO ISDN 3x 5 mg SL
• PO Ramipril 1 x 5 mg
• PO Atorvastatin 0-0-20 mg
PROGNOSIS
• Quo ad vitam : dubia ad malam
• Quo ad functionam : dubia ad malam
• Quo ad sanactionam : dubia ad malam
THANK YOU