Case Report

ST Elevation Miocard Infarction

Anteroseptal

Fitrianto Dwi Utomo

I11111064

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

Cardiology Department Dustira District Hospital

Faculty of Medicine Tanjungpura University
Patients Identity
Name : Mr. X
Gender : Male
Age : 45 Years old
Address : Hujung Kidul RT 8 RW 7
Admission date : September 28th 2017
Chief Complaint
Chest pain
History of Present illness
Patient attended to Emergency department complaining of chest pain 1
hour ago.
Chest pain describes as feeling as if someone were standing on his chest
or squeezing his chest.
Chest pain was radiating to the back, neck and left leg. It was persistent
about 20 minutes.
Chest pain also followed by shortness of breath, diaphoresis, pain in the
epigastrium and nausea
Past illness History
History of hypertension
No history of cholesterol, heart disease, stroke, diabetes melitus,
kidney and liver disease.
Family History
History of hypertension in family (-)
History of heart disease in family (-)

Personal and social history

Patient was an active smoker at the last 20 years and have been stop 2 year
ago.
 Physical Examination
BP = 160/110 HR = 84 bpm, RR = 24 T ax 36,5 C SaO2 = 99%
mmHg reguler tpm

General appearance looked GCS E4V5M6

moderrate
Head Wnl
Neck Wnl
Cor SI/SII reguler, mur mur (-)

Pulmo Auscultation : breath sound v v Rh - - Wh - -

v v -- - -
v v -- - -

Abdomen Wnl

Extremities Wnl
Laboratory Findings
Hb : 18,2 g%
Erythrocytes : 6,0 x 106 /uL
Leukocytes : 9.100/uL
Ht : 52.1 %
Platelets : 285.000/ uL
MCV : 87,3 fl
MCH : 30,5 pg
MCHC : 34,9 g/dl
RDW : 12,9%
Ba/Eo/Sg/Li/M: 0,7/2,4/39,8/52,7/5,6
Random Blood Glucose: 121 mg/dl
CKMB: 32 U/L
Electrocardiography

Rhythm: sinus rhytm

Frequency: 84 bpm reguler
Axis : normoaxis
QRS complex : 0,08 ms
Abnormality:
ST elevation in V2, V3, V4
Conclusion : STEMI anteroseptal
Initial Diagnosis
Clinical Diagnosis : Acute Coronary Syndrom STEMI
Anatomical Diagnosis : Anteroseptal Myocardial Infarc
Etiological Diagnosis : Atherosclerosis
Management
In Emergency Departement:
Bed Rest
Semi fowler position
Fasting
Plug the catheter
IV line
Drip Nitrogliserin 10 mcg/minutes
P.O Aspirin loading 320 mg
P.O Clopidrogel loading 300 mg
 Emegency PCI available within 90 minute? If
available go to primary PCI
If there is no available PCI within 30 minutes go to
fibrinolytic therapy. Fibrinolytic therapy:
streptokinase 1,5 millions unit in 100 ml D5%
 In this case we dont use fibrinolytic because
diastol pressure 110 mmHg, onset chest pain
when admission to ER > 1 hour.
In this case we should do Primary PCI
Prognosis
Quo ad vitam : dubia ad malam
Quo ad functionam : dubia ad malam
Quo ad Sanactionam : dubia ad malam