MORNING REPORTBAGIAN/SMF ILMU KARDIOLOGI FAKULTAS KEDOKTERAN UNIVERSITAS SYIAH KUALARUMAH SAKIT UMUM DR. ZAINOEL ABIDINBANDA ACEH2015

31 Maret 2015

NOIDENTITAS AssPlan1Basri, 47 Tahun, Laki-lakiSTEMI Anterior EkstensifDM Tipe IIRawat ICCUdr/ur/cr/elektrolit/ kolesterol lengkap/ as. Urat/ GDS/ CKMB/ Troponin IUrinalisaECHOFoto Thorax 2Ainon Mardhiah, 69 tahun, perempuanAkut NSTEMI dd UAP tipe Frist onsetHipertensi Stage IIRawat ICCUdr/ur/cr/elektrolit/ kolesterol lengkap/ as. Urat/ GDS/ CKMB/ Troponin IUrinalisaECHOFoto Thorax

STEMI ANTERIOR EKSTENSIF ONSET >2 JAM KILLIP I TIMI RISK SCORE 1/14??Disusun oleh:Edho Biondi Joris

Supervisor :dr. ,Sp.JP,FIHABAGIAN/SMF ILMU KARDIOLOGI FAKULTAS KEDOKTERAN UNIVERSITAS SYIAH KUALARUMAH SAKIT UMUM DR. ZAINOEL ABIDINBANDA ACEH2015

Identitas PasienNama: Tn. BUmur: 47 TahunAlamat: IndrapuriAgama: IslamStatus Perkawinan: MenikahSuku: AcehNomor CM: 0-98-78-70Pekerjaan: PNSTanggal masuk : 31 Maret 2015

AnamnesaKeluhan Utama: Sesak nafasRiw. Penyakit Sekarang:Pasien datang dengan keluhan sesak nafas, sesak nafas dirasakan sejak sore sekitarOccurred since about 7 hours before admitted to the hospital. On the left side the chest pain feels dull heavy pain, it seems to radiates to the back. It does not radiate to the shoulder/arm. Chest pain last for 30 minutes. The pain is not lessen at rest or with medication.Patient had experienced chest pain for a year long.However, patient did not check it to the hospital, because at that time the pain it did not disturb his everyday activities and lessen at rest.The chest pain accompanied with shortness of breath, cold sweat (+), fever (-), cough (-), nausea (+), vomit (+), epigastric pain (-). Defecation and urination normal.

Riwayat Penyakit Dahulu:Pasien telah menderita diabetes mielitus sejak 2 tahun yang lalu. Riw. Penyakit Keluarga: Ayah pasien menderita hipertensi. Riwayat sakit jantung dan DM di keluarga disangkal.

Riwayat Pengobatan:Obat dari pulang rawatan di RS kesdam

Riwayat Kebiasaan Sosial:Pasien sering mengkonsumsi rokok. Dalam 1 hari bisa stengah sampai 1 bungkus rokok yang dihabiskan. Pasien juga sering mengkonsumsi makanan berlemak dan tidak pernah menjaga pola makan. Pasien juga mengaku tidak teratur berolahraga.

Pemeriksaan FisikKesadaran: CM (E4M6V5)Tekanan Darah: 120/80 mmHgNadi: 83x/menitPernafasan: 28 x/menitSuhu: 36,7 oC

Status InternusKepalaRambut: HitamWajah : simetris, oedema (-), deformitas (-)Mata: Conjunctiva pucat (-/-), ikterik (-/-), refleks cahaya (+/+), Pupil bulat isokor 3 mm/3mmTelinga: Serumen (-/-)Hidung: Sekret (-/-)

Status InternusMulutBibir: Simetris, bibir pucat (-), mukosa basah (+), sianosis (-)Lidah: Tremor (-), hiperemis (-)Tonsil: Hiperemis (-/-), T2 T2Faring: Hiperemis (-)

LeherInspeksi: Simetris, retraksi (-)Palpasi: TVJ R-2 cmH2O, Pembesaran KGB (-)

Status InternusThoraxInspeksiStatis: Simetris, bentuk normochestDinamis: Pernafasan thoracoabdominal, retraksi suprasternal (-), retraksi intercostal (-), retraksi epigastrium (-)Palpasi : NT (-), Stem fremitus kanan = stem fremitus kiriPerkusi: Sonor/SonorAuskultasi : Vesikuler (+/+), Rhonki (-/-), Wheezing (-/-)

Status InternusJantung

Inspeksi: Ictus Cordis tidak terlihat

Palpasi: Ictus cordis teraba di ICS V linea axillaris anterior

Perkusi: Batas jantung atas di ICS III LMCSBatas jantung kanan di ICS V Linea Parasternalis DekstraBatas jantung kiri di ICS V linea axillaris anterior

Auskultasi : BJ I > BJ II, regular, bising (-), gallop (-)

Status InternusAbdomen

Inspeksi: Simetris, distensi (-), vena kolateral (-) Palpasi: Nyeri Tekan (-)epigastrium, defans muscular (-)Hepar: tidak terabaLien: tidak terabaGinjal: Ballotement (-)Perkusi: Timpani, shifting dullness (-)Auskultasi : Peristaltik normal

Status InternusGenitalia : Tidak diperiksa

Anus : Tidak diperiksa

Kelenjar Limfe Pembesaran KGB : Tidak ada

Status InternusEkstremitas

UdemPucat

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Gambaran EKGIrama: aritmiaRate: 120x/iAxis: NormoaxisGel P : sulit dinilaiPR Interval: sulit dinilaiQRS duration: 0,08 sST elevasi: -ST depresi: -T inverted: -

Kesimpulan :AF RVR

Pemeriksaan LaboratoriumPemeriksaan Laboratorium (31 Maret 2015)

Jenis Pemeriksaan20/3/2015Nilai rujukanHemoglobin13,714-17 gr/dlLeukosit9,24.1-10.5 x 103/ulTrombosit500150-400 x 103/ulHematokrit4045.0-55.0 %Ureum darah4313-43 mg/dlCreatinin darah1,800.51-0.95 mg/dlGula darah puasa329

Foto ThorakCor = Bentuk normal dan ukuran membesar ke kiri Pulmo = tak tampak infiltratSinus phrenicocostaslis kanan dan kiri tajam Kesimpulan= Cardiomegali

DiagnosaSTEMI Anterior EkstensifDM Tipe 2

TerapiBed rest 02 2-4 l/iIVFD RL 10 gtt/IProxime 1x1Pantoprazole 2x1Pravastatine 1x20mgTanapress 5mg 2x1/2 tabFarsorbid 5mg 3x1 tabMiozidine 2x1Clopidogrel 75mg 1x1Sc Lovenox 2x0,6cc

TERIMA KASIH

HISTORY TAKING

PHYSICAL EXAMINATIONGeneral StatusModerate Ilness/ Overweight/ConsciousBody Weight:70 kgBody Height:170 cmBody Mass Index: 24,2 kg/m2

Vital SignsBP: 150/100mmHgHR: 96 bpm, regularRR: 28 bpm T: 36,5C

Head and Neck Examinations:Eye : Conjunctiva anemic (-/-), Sclera icteric (-/-) Lip : Cyanosis (-)Neck : JVP R +2 cmHO

Chest ExaminationInspection: Symmetric between left and right chest.Palpation: No mass, no tenderness.Percussion: Sonor between left and right chest, lung- liver border in ICS IV right anterior .Auscultation:Breath Sounds: VesicularAdventitious breath sound : Ronchi -/-, wheezing -/-

PHYSICAL EXAMINATION

Cardiac ExaminationInspection: Heart apex was not visible Palpation : Heart apex was not palpable Percussion: Dull, left heart border left midclavicular line ICS V.Auscultation: Heart Sounds : S I/II regular, murmur (-) gallop(-)

PHYSICAL EXAMINATION

PHYSICAL EXAMINATIONAbdominal Examination Insp.: Flat and following breath movementAusc.: Peristaltic sound (+), normalPalp.: Liver and spleen is unpalpablePerc.: Tympani (+), ascites (-)

Extremities Oedema: Pretibial -/-, Dorsum pedis -/-

ELECTROCARDIOGRAM (ECG)ECG :Sinus rhythm, QRS rate 83 bites/ minute, north west axis, PR interval 0,16 s, P wave 0,08 s, QRS comlex 0,08 s, Q patologis III, aVF, V1-V3 ST segment elevation V1-V5

Conclution : sinus rhythm, HR 83 bite/minute, whole anterior acute myocard infraction , old myocard infraction inferior

ELECTROCARDIOGRAM (ECG)

ECG :Sinus rhythm, QRS rate 93 bites/ minute, right axis devilation, PR interval 0,12 s, P wave 0,08 s, QRS comlex 0,08 s, Q patologis in III, aVF, V1-V3 ST segment elevation in V1-V5

Conclution : sinus rhythm, HR 93 bite/minute, whole anterior acute myocard infraction , old myocard infraction inferior

Laboratorium Finding Complete blood count

TestResultNormal valueWBC9,05 x 103/ul4.0 10.0 x 103RBC4.86 x 106/l4.0 6.0 x 106HGB15.0 gr/dl12 16 HCT44,6 %37 48 PLT141 x 103 /l150 400 x 103

Blood Chemistry

TestResultNormal valueGDS141 mg/dl

Cardiac EnzymesElectrolyte

TestResultNormal valueCK211U/L

CHEST X-RAYSCloudy parahilar accompanied with cardiovascular suprahilar dilatation on both lungsThere is no specific active process seen on both lungsCor CTI widen 0,57 cm, aorta dilated and calcifiedBoth sinuses and diaphragma in good conditionBones intact

Impression: Cardiomegaly with signs of Pulmonary edemadilatation et atherosclerosis aorta

WORKING DIAGNOSIS1. ST elevation myocardial infarction (STEMI) whole anterior onset >6 hours KILLIP I,2. Old myocard infraction inferior3. Grade I hypertension

MANAGEMENTO2 2 -4 Lpm IVFD NaCl 0,9% 10 drops/min Aspilet 80 mg 0-1-0 Aspirin (Antiplatelet) Plavix 75 mg 0-0-1 Clopidogrel (Antiplatelet)Injection ISDN 0,5 mg/hours/SP NitratCaptopril 25 mg 1-1-1 ACE-InhibitorSimvastatin 20 mg 0-0-1 Statin (Anticholesterol)Alprazolam 0,5 mg 0-0-1 Antianxietas Laxadyn syr 0-0-2 c

PLANNINGCoronary angiography

ST ELEVATION MYOCARDIAL INFARCTION

DEFINITIONMyocardial infarction (MI) rapid development of myocardial necrosis caused by a critical imbalance between the oxygen supply and demand of the myocardium. This usually results from plaque rupture with thrombus formation in a coronary vessels, resulting in an acute reduction of blood supply to a portion of the myocardium.

PATHOPHYSIOLOGYOccurs when coronary blood flow decreases abruptly after a thrombotic occlusion of a coronary artery previously affected by atherosclerosis.In most cases, infarction occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates.

Lipid transport disorderInflamation Plaque depositionStable plaquePlaque ruptureErosion Stable angina pectorisThrombosisThrombusAcute coronary syndrome: Unstable angina Myocardial infarction :- Non Q waves- Q wavesPATHOGENESIS

RISK FACTORGender and Age Men, increased risk after age 45 Women, increased risk after age 55Family History Heart disease diagnosed before age 55 in father or brother Heart disease diagnosed before age 65 in mother or sister

Non- Modifiable

Modifiable

SmokingHypertensionDiabetes MellitusDyslipidemiaObesityLack of physical activity

Prolonged pain (usually >20 minutes) constricting, crushing, squeezingUsually retrosternal location, radiating to left chest, left arm; can be epigastric Dyspnea Diaphoresis Palpitations Nausea/vomiting CLINICAL MANIFESTASION

WHO DIAGNOSTIC CRITERIAClinical history of ischemic type chest pain lasting >20 minutesChanges in serial ECG tracingsRise and fall of serum cardiac biomarkers such as creatinine kinase-MB fraction and troponin

ECG CHANGES Timing of myocardial infarction based on ECG

SERUM CARDIAC MARKER ELEVATIONS

NoYesYesNoSTEMI

Acute Myocardial Infarction

( Q-wave, non-Q wave )

NSTEMI

(No ST-Segment Elevation

Myocardial Infarction)Unstable AnginaSigns of myocardial ischemia ST segmen elevation ?Biochemical cardiac markers ?DIAGNOSISECGLab

INITIAL TREATMENTBed RestDietOxygen (2-4L/mnt)Anti platelet therapy : Aspirin 160-325 mg chewed immediately and 81-162 mg continued indefinitely.Clopidogrel 300-600 mg loading dose and 75 mg daily continued for at least 14 days and up to 12 monthsNitroglycerinISDN 10 mg or 20 mg, 2-3 a day. ISDN 5 mg SL when chest pain.

INITIAL TREATMENTMorphine 2,5-5 mg or pethidin 12,5-25 mg iv ACE I (Captopril 12,5-25 mg )Fibrinolytic therapy:a) Streptokinase 1.5million units iv b) Tenecteplase 0.5mg/kg body weight iv.Anticoagulation therapy:a) Low Molecular Weight Heparins ( Fondaparinux) 2.5mg/24hrs/sc for up to 8 days post-MI.StatinsSimvastatin 20 mg

PROGNOSISKILLIP CLASSIFICATION

ClassDescriptionMortality Rate (%)INo clinical signs of heart failure6IIRales or crackles in the lungs, an S3, and elevated jugular venous pressure17IIIAcute pulmonary edema30 - 40IVCardiogenic shock or hypotension (systolic BP < 90 mmHg), and evidence of peripheral vasoconstriction60 80

PROGNOSIS TIMI SCORE

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