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ST SEGMENT ELEVATION MYOCARDIAL

INFARCTION (STEMI) EXTENSIVE ANTERIOR

ONSET 5 HOURS KILLIP I

M. A. AirlanggaC11109258

Supervisor:

dr. Khalid Saleh, Sp.PD-KKV, FINASIM

CASE PRESENTATION

DEPARTMENT OF CARDIOLOGY AND VASCULAR MEDICINE

MEDICAL FACULTY OF HASANUDDIN UNIVERSITY

MAKASSAR

2013

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PATIENT IDENTITY Name : Mr. AS

Age : 59 years old

Medical record : 63-38-40

Room : CVCU bed 2

Admission date : October 23rd, 2013

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HISTORY TAKING

Chief complaint : Chest pain

Chest pain began at about 5 hours before entering the hospital

Chest pain appeared when patient was at rest and last for about anhour

Pain described as burning sensation on the chest and penetrating to hisback

Patient feel shortness of breath when chest pain appeared (chestdiscomfort), palpitation, sweating, and weakness

Patient could sleep with one pillow and sleep was not interrupted by

shortness of breath No. Fever. No cough. No nausea and vomiting. No history of epigastric

pain.

Defecation and urination : normal

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HISTORY TAKING

History of past illness History of hypertension (+) for 20 years, treated uncontinuously

History of diabetes mellitus (+) for 13 years, treated uncontinuously

History of smoking (+) 1 pack/day for about 40 years.

History of haemorrhagic stroke on 2010 No history of heart disease

No history of family with heart disease

No history of asthma

No history of gastritis

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RISK FACTOR

Modifiable Smoking

Diabetes Mellitus

Hypertension

Unmodifiable Gender : Man

Age : 59 years old

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PHYSICAL EXAMINATION General status

Moderate illness/overweight/conscious

Vital sign

Blood Pressure : 160/100 mmHg

Heart Rate : 106 bpm

Respiration Rate : 28 bpm

Temperature : 36,7C

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PHYSICAL EXAMINATION Head

Eyes : anemia (-), icterus (-)

Lips : cyanosis (-)

Neck :lymphadenopathy (-), JVP R+1 cmH2O

Thorax

Lungs

Inspection : symmetric, normochest

Palpation : mass (-) tenderness (-) FT left = right

Percussion : sonor

Auscultation : Breath sound : vesicular

Additional sound : ronchi (-/-) wheezing (-/-)

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PHYSICAL EXAMINATION Thorax

Heart

Inspection : ictus cordis not visible

Palpation : ictus cordis not palpable

Percussion : dull, normal heart size

Upper border : left 2ndICS Lower border : left 5thICS

Right border : right parasternalis line

Left border : left medioclavicular line

Auscultation : regular I/II heart sound, murmur (-)

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