Diapositiva 1

CASE REPORTST Elevation Myocardial Infarction Extensive Anterior Onset 1 hour KILLIP Iby : Dewi Wahyuni SupangatC 111 08 Supervisor :Dr. dr. Idar Mapanggara Sp.PD Sp.JP FIHA Universitas Hasanuddin2015Patients IdentityName: Mr. A.P Age: 60 years oldAddress : AP. Pettarani streetMedical Record : 577891Date of admission: 10th of April 2015

History Taking Chief complaint: Chest painPresent Illness History :Left chest pain felt since 1 hour before admission Described as a compressed and continuous pain, radiating to the left arm, intermittently, duration of pain was over 30 minutes. Pain worsen by activities and does nt relieve with restingAccompanied with sweatThere is dyspneaNo extremity oedem

Past Illness HistoryPast Illness History :History of hypertension since 4 years ago, still on treatmentHistory of smoking, 1 to 2 packs per day since about 18 years old, but he was quite since 2 years agoNo history of heart attack No history of chest pain beforeNo history of Diabetes MellitusNo history of alcohol consumption

Physical ExaminationGeneral StatusModerate illness / Overweight / ComposmentisWeight: 70 kgHeight: 174 cmBMI: 23,05 kg/m2Vital StatusBlood pressure :140/90 mmHgHeart rate : 64 bpmRespiratory rate : 22 rpmTemperature : 36,7 oC

Physical ExaminationHead: anemic (-) icteric (-) Neck: JVP R+2 cmH2O, Lung:Inspection : symmetry left=rightPalpation : mass (-), no tenderness, normal vocal fremityPercussion : sonorAuscultation : vesicular, ronchi -/-, wheezing -/-

Physical ExaminationCor :Inspection: ictus cordis not visiblePalpation: ictus cordis not palpable, thrill (-)Percussion: Upper border on 2nd sinistra ICSRight border on linea parasternalis dextra 4th ICSLeft border on linea axillaris anterior sinistra 5th ICSAuscultation: I/II pure heart sound , regular, murmur (-)Physical ExaminationAbdomen :Inspection : flat, follows breath movementAuscultation: peristaltic (+), normalPalpation: liver and spleen not palpablePercussion: tympani

Extremities : Edema (-)Electrocardiography

Sinus : rhythmHeart rate : 64bpmAxis : normoaxisP Wave : 0,08 sPR interval : 0,12 sDuration QRS: 0,08 sST segment : ST elevation on lead 1, aVL, V1-V6ST depresion : II,III, AVF

Conclusion :Sinus rhythm, HR 64 bpm, normoaxis, ST elevation on lead I, avL, V1-V6(Antero-septal myocard infarction)Laboratoratory (10th of Mei 2015)TESTRESULTNORMAL VALUEWBC12,4x 103/uL4.0 10.0 x 103RBC4,13 x 106/uL4.0 6.0 x 106HGB13,6g/dL12 18 HCT39,6%37 48 PLT286 x 103/uL150 400 x 103PT10,6 ctrl 11,510 - 14APTT21,5 ctrl 22,522,0 - 30,0Blood ChemistryTestResultNormal valueUreum3310-50Creatinine1,140,5-1,2SGOT25 u/L