LAPORAN KASUS

IGD RSIJ
SUKAPURA
7 OKTOBER 2016

Dokter Jaga UGD : dr. Mirad

Dokter Pendamping Internsip : dr. Hendry
Dokter Internsip : dr. Rizki Arya

1. TN A (54 THN)

RPS
Pasien datang ke UGD RSIJ Sukapura dengan keluhan
nyeri dada 15 menit sebelum masuk rumah sakit,
Keluhan dirasakan menjalar ke lengan kiri dan ke
punggung pasien, nyeri dirasakan terus menerus,
pasien mengatakan nyeri seperti ini sudah pernah
dirasakan sebelumnya tetapi membaik dengan
istirahat, riwayat hipertensi (+), terkontrol dengan
bisoprolol 5 mg. Pasien juga mengeluhakan mual (+),
muntah (+), dan juga lemas serta keringat dingin

PRIMARY SURVEY
Circulation :
Cold extremities
BP
: 122/83
Pulse
: 78 x/menit
RR
: 21 x/menit
Temp
: 36,60C
CRT <2
Airway
Look
Listen
Feel

: CLEAR
: no obstruction
: no extra breath sound
: there were warm air from both nose and mouth

Breathing
Ins
Pal
Per
Aus

: CLEAR
: chest wall movement symmetrical, RR 21x/min
: vocal fremitus symmetrical
: sonor right = left
: basic breath sound vesicular, rh -/-, wh -/-

 Disability
GCS 15 (E4M6V5)
pupil isochoric 3/3 mm, centered
Direct light reflex/indirect light reflex +/+

Exposure
There was no life threatening wounds

GENERAL STATUS

GCS 15, composmentis

BP
: 122/83
Pulse
: 78 x/menit
RR
: 21 x/menit
Temp
: 36,60C

HEAD TO TOE

Head
Eyes

Ear
Neck

: Normocephaly
: Pupil circular, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+, Indirect
Light Reflex +/+, CA -/: Normal, Blood (-)
: Bruise (-), Hematoma (-)

Thorax :

- Inspection

: bruise (-), movement of chest wall

symmetrical
- Palpation : Vocal fremitus symmetrical
- Percussion : sonor right=left, percussion pain (-)
- Auscultation : basic breath sound vesicular
right=left, wh-/-, rh-/-.

Abdomen :

-Inspection
-Auscultation
-Palpation

: flat
: bowel sound (+) 4x/min
: tenderness (-), defense muscular
(-), pain palpation (-), CVA -/-Percussion : tympani, percussion pain (-)

EXTREMITY

CRT < 2
Sianosis
Edema
Akral

:/
:/
: cold

EKG

WORKING DIAGNOSE
STEMI
(ST ELEVATION MYOCARD INFARK)

TREATMENT
Non-Medicamentosa:
-O2 3 Lpm
Medicamentosa :
ISDN 4 x 10mg
Clapidogrel 4 x 75mg
Aspilet 4 x 81mg

TERIMA KASIH