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Case report by:

Siti Hani Amiralevi


I4061162037

Preceptor:
Letkol (CKM) dr. Prihati Pujowaskito, Sp. JP (K), MMRS

Cardiology Department Dustira District Hospital


Faculty of Medicine Tanjungpura University
2018
 Mr. D/ 62 y.o/ Ceremai Room
 Chief Complaint: Chest Pain
 Patient suffered chest pain since a week before
admitted to the ER, but getting worse in last 7 hours.
 The chest pain appeared suddenly without any trigger,
felt heaviness radiated to the left arm, intermittent,
lasted about 25 minutes, relieved by resting.
 The complaint also accompanied by nausea and
dyspnoea.
 Patient had uncontrolled hypertension and cholesterol.
 His father had hypertension and died because of
stroke.
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BP = 110/90 mmHg HR = 119 bpm, RR = 36 tpm  T = 36.5 celcius
regular  tachycardia tachypnoea SpO2 = 92% on free
air
Weight : 77 kg, height : 164 cm  BMI : 28.7  Overweight
General appearance : looked moderately ill GCS E4 V5 M6  compos mentis
Head Anemic (-) Icteric (-)
Neck JVP 5+2 cmH2O
Thorax Retraction (-), Ictus Cordis not seen.
Cor S1 S2 single, mur mur (-), gallop (-) extrasystole (-)
Pulmo Simetric, SF D = S Rh -/- Wh - /-

Abdomen Convex, Soefl, Hepar : Liver span 11 cm, spleen traube space
tympani. Tenderness (-)
Extremities Oedema ( -/-)
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10/05/2018 11/05/2018
 Hemoglobine : 15,1 g/dl  Ureum : 44 mg/dl
 Eritrosite : 5,2 x 106/µl  Creatinine serum : 1.3 mg/dl
 Leukocyte : 6.600/µl  Sodium : 132 mmol/l
 Hematocryte : 44.5%  Pottasium : 4.40 mmol/l
 Chloride : 103 mmol/l
 Platelet : 254.000/µl  Troponin I : >10 ng/ml
 MCV : 86.4 fl  Trigliserida : 85 mg/dl
 MCH : 29.3 pg  LDL Cholesterol : 161 mg/dl
 MCHC : 33.9 g/dl
 RDW : 13,2%
 Ba/Eo/Sg/Li/M:
0.5/0.0/81.9/11.9/5.7 % GRACE Score : 132 points
(intermediate risk)

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 Rhythm : Sinus tachycardia
 Freq : 115 bpm
 Axis : Normoaxis
 P wave : 0.12 s
 P-R interval: 0.2 s
 Q wave : qs pattern lead V1-V3
 QRS wave : 0.8 s
 ST segment : ST depression lead V4-V6
 T wave : Hyperacute T (-) & T inverted lead II, III,
aVF
 QT interval : QTc: 0.36 s
 Abnormalities : inferolateral NSTEMI and anteroseptal
OMI
 Conclusion : Sinus tachycardia with inferolateral
MI and anteroseptal OMI
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Clinical Diagnosis
 Inferolateral NSTE-ACS, anteroseptal OMI

Etiologic Diagnosis
 Atherosclerosis

Anatomic Diagnosis
 Inferolateral, anteroseptal myocardial infarction

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Non medical: Long Term Treatments
 Total Bedrest • Control risk factor
 Semifowler position • IV Enoxaparin 0.6 mg twice a
day
• Sublingual ISDN 5 mg prn
Medical
• PO Aspirin 100 mg once a day
 O2 3 lpm via nasal canula • PO Ticaglerol 90 mg twice a
 IV access day
 IV Nitroglycerin 20mcg/min • PO Bisoprolol 2.5 mg once a
day
 PO Aspirin loading 300 mg
• PO Atorvastatin 40 mg 0-0-1
 PO Ticaglerol loading 180
mg
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 Primary PCI

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 Quo ad vitam : dubia ad malam
 Quo ad sanactionam : dubia ad malam
 Quo ad functionam : dubia ad malam

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