EMERGENCY DEPARTMENT CASE PRESENTATION 19TH OF MARCH 2014

EMERGENCY DEPARTMENTCASE PRESENTATION19TH OF MARCH 2014INTAN EKARULITAMELISA AYUName: Mr. D U

Address : Jalan Adan RT 6/11, Rawa Belong, Jakarta Barat

Date of Birth: 04th of July 1968

Age: 46 years oldIDENTITYChief Complaint:Chest pain since 6 hours before he came to hospital

Additional Complaints :Shortness of breathDizziness

History TakingPatient came with chest pain since 6 hours before he came to the hospital.The pain felt all over his chest area.It happened suddenly after he got cough.The pain felt like his chest pressed which worsens while he was walking.It felt continuously and did not radiate to any other parts of his body. Disease ProgressionShortness of breathIt felt at the same time with his chest pain.It was getting better when he was lying down and getting worse when he was walking. DizzinessIt was the first time he felt this symptomsHe used one pillow while lying down.Palpitation (-), abdominal discomfort (-)Disease ProgressionThe patient is a smoker since 25 years ago.10 cigarettes per dayDisease ProgressionTaking drugs (-)Heart disease (-)Diabetes Mellitus (-)High Cholesterol (-)Hypertension (+)Since 2 years agoDid not take any medicine Diseases HistoryGeneral State : Appeared severely illAwareness: Compos MentisVital Signs:BP: 130/80 mmHgHR: 83 x/minuteRR: 20 x/minuteTemp: 36,7CPhysical ExaminationHead: normocephal

Eyes: anemic conjunctiva -/-, icteric sclera -/-, palpebral edema -/-, pupil isokor, light reflexes +/+

ENT: nostril breath (-), secrete (-), hyperemic pharynx (-), tonsils T2-T2

Neck: impalpable lymph node, JVP 5+2cmH20 Thorax: normochest, discoloration (-) Lungs:hemithorax moved symmetrically, retraction (-)vocal fremitus : symmetricSonor in all area of the thoraxVesicular breath sound, wheezing (-/-), rhonki(-/-)

Heart:Ictus cordis : invisible, palpable at ICS V midclavicular line sinistraHearts borderlineRight : ICS V parasternal dextraApex : ICS V midclavicular sinistraSuperior: ICS II parasternal sinistraS I&II regular, murmur (-), gallop (-)

AbdomenSupel, spider naevi (-), scar (-), caput medusa (-)Distention (-), skin turgor : normal, pain on palpation (-), massa (-), hepar and spleen : normalTymphanic sound on all area of abdomenPeristaltic (+), normalExtremitiesWarm on all four extremitiesNo edema on all extremitiesNo clubbing fingersECGRoentgen ThoraxLaboratory Test : CKMB, troponin I dan T, HDL, LDL, TG, Cholesterol Total, and Random Blood Glucose.Diagnostic ToolsLAB RESULTSHb 14.5Ht 44%Eri 5.9Leukocytes 13400Thrombocytes 373000CPK 1012CKMB 166Ureum 45Kreatinin 1.7GDS 147Na/K/Cl 138/4.4/102ECG

ST Elevation in lead IST Depression in lead III

ECGST Elevation in Lead I, aVL, V6ST Elevation Myocard InfarctWorking DiagnosisO2 in nasal cannuleCPG 4 x 75 mgAspirin 1 x 160 mgSimvastatin 1 x 20 mgISDN 1 x 5 mg sublingualStreptokinase 1.5 millions Unit in 1000 NaCl drips in 60 minutes

TREATMENTTHANK YOUAnamesis sudah menunjukan gejala typical anginaFoto rontgen seharusnya tetap dilakukan untuk mengetahui adanya hipertrophy jantung untuk menentukan KIPI score sebagai prognosisMenentukan TIMI score Pengobatan terbaik seharusnya PCI namun tidak dilakukan di IGDCOMMENTS