Professional Documents
Culture Documents
Preceptor:
Letkol (CKM) dr. Prihati Pujowaskito, Sp. JP (K), MMRS
Abdomen Convex, Soefl, Hepar : Liver span 11 cm, spleen traube space
tympani. Tenderness (-)
Extremities Oedema ( -/-)
3
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)
4
5
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
6
Clinical Diagnosis
Inferolateral NSTE-ACS, anteroseptal OMI
Etiologic Diagnosis
Atherosclerosis
Anatomic Diagnosis
Inferolateral, anteroseptal myocardial infarction
7
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
8
Primary PCI
9
Quo ad vitam : dubia ad malam
Quo ad sanactionam : dubia ad malam
Quo ad functionam : dubia ad malam
10