Skenario A Blok 13

Mr. ZM, 69 years old, retired from government employee, comes to dr. Moh Hoesin
General Hospital because he has been heaving epigastric pain since ten hours ago while he
was walking in the his garden and it does not relief even when he take a rest. The pain
radiated to this lower jaw and ulna area, and it felt like burning. He was unconciousness for
three minutes. He also complained shortness of breath, sweating, and neuseous. He has
history of hypertension and sedentary life style. He has been smoking since 17 years old, two
packs a day.

Physical Exam :
Dyspnea, height : 160 cm, body weight : 68 kg, BP : 160/100 mmHg, PR : 50 bpm, HR : 50
bpm regular equal. RR : 30 x/min
Pallor, diaphoresis, JVP (5-2) cmH2O, muffle heart sounds, left cardiac border ICS VI linea
axillaris anterior sinistra, basal rales (+) on both side, liver : not palpable, ankle edema (-)

Laboratory Result :
Hemoglobin : 14 g/dL, WBC : 9.800/mm3, Diff count : 0/2/5/65/22/6, ESR 20/mm3, Platelet :
214.000/mm3
CK NAC 570 U/L, CK MB 90 U/L, ureum 25 mg%, creatinin 0,9 mg%

ECG Result :
Sinus rhythm, left axis, HR : 50 bpm, PR interval 0,28 sec, ST elevation at lead II, III, aVF
and ST depression at lead VI, V2, V3, VES benigna (+), LV strain (+)
I. Klarifikasi Istilah
No. Klarifikasi Istilah Pengertian
1. Epigastric pain Pain located between the xiphoid process and
the umbillicus (Farlex)
2. Lower jaw Lower bony or cartilaginous structures that in
most vertebrates from the framework (Farlex)
3. Ulna area The medial aspect of the upper forelimb
(Farlex)
4. Sedentary life style Sedentary behavior as any activity involving
sitting, reclining, or lying down that has a bery
low energy expenditure (SBRN)
5. Pallor Paleness especially of the face that is caused
by illness (Merriam Webster)
6. Diaphoresis Berkeringat berlebihan (dorland)
7. Muffle heart sound The heart sound are normal in outline but
muffled, due usually to the presence of fluid
between the heart and the stethoscope
(Medical Dictionary)
8. Basal rales Bising terputus-putus yang terdiri atas bising
pendek, terdengar pada saat inhalasi (Dorland)
9. CK NAC Enzim yang ditemukan terutama di otot
jantung, otot lurik dan jaringan otak dimana
peningkatannya berhubungan dengan
myocardiac infark dan gangguan otot lainnya
(Beckman)
10. CK MB Isoenzim yang ditemukan hampir kebanyakan
di myocardium dan peningkatan kadar CK MB
dalam serum sangat sensitif pada injury
dinding sel myocard (NCBI)
11. Sinus rhythm Irama jantung normal yang berasal dari nodus
SA (dorland)
12. VES benigna Ectopic impulses originating from an area
distal to the His Purkinje System (Medscape)
13. LV strain Measures of deformation that reflect left
ventricular function (european heart journal)
 II. Identifikasi Masalah
No. Identifikasi Masalah Prioritas
1. Mr. ZM, 69 years old, has been having epigastric pain since ten VVV
hours ago while he was walking in his garden and it does not
relief even when he take a rest. The pain radiated to his lower
jaw and ulna area, and it felt like burning. He was
unconciousness for three minutes. He also complained shortness
of breath, sweating, and neuseous.
2. He has history of hypertension and sedentary life style. He has VV
been smoking since 17 years old, two packs a day.
3. Physical Exam : V
Dyspnea, height : 160 cm, body weight : 68 kg, BP : 160/100
mmHg, PR : 50 bpm, HR : 50 bpm regular equal. RR : 30 x/min
Pallor, diaphoresis, JVP (5-2) cmH2O, muffle heart sounds, left
cardiac border ICS VI linea axillaris anterior sinistra, basal rales
(+) on both side, liver : not palpable, ankle edema (-)
4. Laboratory Result : V
Hemoglobin : 14 g/dL, WBC : 9.800/mm3, Diff count :
0/2/5/65/22/6, ESR 20/mm3, Platelet : 214.000/mm3
CK NAC 570 U/L, CK MB 90 U/L, ureum 25 mg%, creatinin
0,9 mg%
5. ECG Result : V
Sinus rhythm, left axis, HR : 50 bpm, PR interval 0,28 sec, ST
elevation at lead II, III, aVF and ST depression at lead VI, V2,
V3, VES benigna (+), LV strain (+)

III. Analisis Masalah

1. Mr. ZM, 69 years old, has been having epigastric pain since ten hours ago
while he was walking in his garden and it does not relief even when he take a
rest. The pain radiated to his lower jaw and ulna area, and it felt like burning.
He was unconciousness for three minutes. He also complained shortness of
breath, sweating, and neuseous.
a. Bagaimana hubungan usia, jenis kelamin dengan keluhan pada kasus?
Laki-laki, usia lebih tua biasanya pembuluh darahnya kurang elastis
b. Apa saja yang dapat menyebabkan nyeri epigastric?
Refluks asam lambung, ada lagi…. Lupa
c. Mengapa nyeri tidak hilang ketika beristirahat?
d. Bagaimana mekanisme perambatan nyeri?
dermatom
e. Bagaimana mekanisme penurunan kesadaran pada kasus?
Pada ureum tinggi bisa menyebabkan penurunan kesadaran
f. Mengapa nyeri terasa seperti terbakar pada kasus?
g. Bagaimana mekanisme sesak napas pada kasus?
h. Bagaimana mekanisme berkeringat pada kasus?
Berhubungan dengan aktivasi saraf simpatis
i. Bagaimana mekanisme mual pada kasus?
 2. He has history of hypertension and sedentary life style. He has been smoking
since 17 years old, two packs a day.
a. Bagaimana hubungan hipertensi dengan keluhan pada kasus?
b. Bagaimana hubungan gaya hidup sedentary dengan keluhan pada
kasus?
c. Bagaimana hubungan merokok sejak umur 17 tahun dengan keluhan
yang dialami?

3. Physical Exam :
Dyspnea, height : 160 cm, body weight : 68 kg, BP : 160/100 mmHg, PR : 50
bpm, HR : 50 bpm regular equal. RR : 30 x/min
Pallor, diaphoresis, JVP (5-2) cmH2O, muffle heart sounds, left cardiac border
ICS VI linea axillaris anterior sinistra, basal rales (+) on both side, liver : not
palpable, ankle edema (-)
a. Bagaimana interpretasi pada kasus?
b. Bagaimana mekanisme abnormal pada kasus? (mekanisme)
c. Apa hubungan IMT dengan keluhan yang dialami?

4. Laboratory Result :
Hemoglobin : 14 g/dL, WBC : 9.800/mm3, Diff count : 0/2/5/65/22/6, ESR
20/mm3, Platelet : 214.000/mm3
CK NAC 570 U/L, CK MB 90 U/L, ureum 25 mg%, creatinin 0,9 mg% LDL
194 HDL 25 Sodium 30 urin acid
a. Bagaimana interpretasi pada kasus?
b. Bagaimana mekanisme abnormal pada kasus? (mekanisme)
c. Mengapa perlu dilakukan pemeriksaan ureum dan creatinin?
d. Mengapa perlu dilakukan pemeriksaan CK NAC dan CK MB?

5. ECG Result :
Sinus rhythm, left axis, HR : 50 bpm, PR interval 0,28 sec, ST elevation at
lead II, III, aVF and ST depression at lead VI, V2, V3, VES benigna (+), LV
strain (+) fotothorax STR > 50%, berbentuk sepatu, bronkovaskuler
meningkat
a. Bagaimana interpretasi pada kasus?
b. Bagaimana mekanisme abnormal pada kasus? (mekanisme) PR
interval memanjang
c. Bagaimana mekanisme pemeriksaan ECG? (penentuan sadapan)

Berdasarkan dari 3 pemeriksaan diatas :

a. Apa diagnosis? Sindrom koroner akut
b. Bagaimana diagnosis banding?
c. Bagaimana epidemiologi?
d. Bagaimana etiologi?
e. Bagaimana Patofisiologi?
f. Bagaimana Algoritma diagnosis?
g. Bagaimana Tatalaksana?
h. Bagaimana Edukasi?
i. Bagaimana Prognosis?
j. Bagaimana Skdi?
 IV. Keterkaitan antarmasalah
Mr. ZM  merokok sejak 17 tahun, sedentary life style riwayat hipertensi
epigastric pain dyspnea

LI
1. Sindroma koroner akut wajib
2. Pemfis inanta, richard, nabila, cece
3. Lab yuda, dodo, deva, wira
4. Ekg ade, alan, hilda, anggie

V. Keterbatasan Ilmu Pengetahuan

VI. Sintesis Masalah
VII. Kerangka Konsep
VIII. Kesimpulan