Case Report

A 47 Years-Old Man Came with Epigastric Pain since About 5 Hours before Admission

By:

Rifkia Izza Maorits, S.Ked.

Risfandi Ahmad TaskuraS.Ked.

Advisor:

Prof. dr. Eddy Mart Salim, Sp.PD, K-AI, FINASIM

Opponents:

Diva Zuniar Ritonga Triara Putri Ramadhani Meirisa Rahma Pratiwi

Randina Dwi Megasari Dina Fatma Dwimarta Dessy Carmelia Nurhadana
Arief Tri Wibowo Ivan Alexander Liando Devuandre Naziat
Dina Sabilah Moh. Wafa Adillah Sandria
Ade Trianda Rizki Tri Nisdian Wardiah Tika Rahma Guci
Febri Rahman Ridhya Rahmayani Muhamad Arief Rahman H.
Wahyu Arfina Juwita Januar Antoni Rifkia Izza Maorits
Rudi Thenggono Ismel Tria Pratiwi Siti Rahma Anissya Kinanti
Rima Fairuuz Putri Tuti Syarach Dita Risfandi Ahmad Taskura
Dico Fatejarum Arisita Firman Nur Annisa Faradina
M. Ramzie Vivien Al-Amirah Zainab
M. Rachmat Budiman Sekarayu Putri Kencana Muhammad Alniroman Y.
Rafenia Nayani Muhammad Salman Alfarisi

DEPARTMENT OF INTERNAL MEDICINE

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
DR. MOHAMMAD HOESIN GENERAL HOSPITAL
2016
 APPROVAL PAGE
Case Report

Title

A 47 Years-Old Man Came with Epigastric Pain since About 5 Hours before
Admission

By:

Rifkia Izza Maorits, S.Ked.

Rsifandi Ahmad Taskura, S.Ked.

Has been accepted and approved as one of the qualification in senior clerkship at Internal medicine
Department of Dr. Mohammad Hoesin General Hospital on October 17 th 2016 December 25th 2016.

Palembang, November 7th 2016

Prof. dr. Eddy Mart Salim, Sp.PD, K-AI, FINASIM

ii
 PREFACE

We would like to thank Prof. dr. Eddy Mart Salim, Sp.PD, K-AI, FINASIM for being our
advisor. We are grateful to accomplish this case report as per schedule without any sort of
inconvenience. We also appreciate the contribution of every individual whom have help us in
completing this repot.

This case report discusses about STEMI. Last but not least, we hope this case report could be
useful for our fellow colleagues in Internal Medicine Department in applying adequate diagnosis and
treatment for patient with STEMI.

Palembang, November 7th 2016

Authors

iii
 CONTENTS

COVER PAGE ....................................................................................................................................... i

APPROVAL PAGE .............................................................................................................................. ii

PREFACE ............................................................................................................................................ iii

CONTENTS ........................................................................................................................................ iv

ABSTRACT ......................................................................................................................................... 1

INTRODUCTION ................................................................................................................................ 1

CASE ILLUSTRATION ...................................................................................................................... 2

DISCUSSION ....................................................................................................................................... 3

CONCLUSION ..................................................................................................................................... 3

REFERENCES ..................................................................................................................................... 4

i
A 47 Years-Old Man Came with Epigastric Pain since About 5 Hours
before Admission
Rifkia Izza Maorits*, Risfandi Ahmad Taskura*, Eddy M. Salim**
ABSTRACT
It was reported a case with epigastric
pain in RSMH. Mr. ZR, a 47 years-old man
came to Mohammad Hoesin General Hospital
with chief complaint of epigastric pain since
about five hours before admission. Seven days
before admission, he felt shortness of breath
which is affected by activity and felt better
after took some rest. He slept using two
pillows and often woke up in the middle of the
night because feeling hard to breath,
sometimes nausea was present. There was no
vomitting, fever, nor cough present. One day
before admission, he felt worse shortness of
breath which came even when he was resting.
He could not sleep, felt palpitation, admitted
there were epigastric pain which radiated to
the back and nausea. Five hours before
admission, he felt severe epigastric pain as if
his upper abdomen was being squeezed. The
pain last for about half an hour and did not
subsided when he rest. He also felt pain in his
back, nausea and sweaty.
Mr. ZR had first history of simillar pain
attack in 2010 which affected by activity. He
has history of stroke in 2012. He also has
diabetes mellitus and hypertension. There is no
history of hypertension nor diabetes mellitus
from his family.
Keywords: STEMI
* Medical Student of Sriwijaya University,
Clerkship Program Dr. Moh. Hoesin General
Hospital
** Staff of Allergy-Immunology Division of
Internal Medicine Department of Dr. Moh.
Hoesin General Hospital
1
INTRODUCTION
ST Segment Elevation Myocardial
Infarction (STEMI) is the name cardiologists
currently use to describe a classic heart attack.
Myocardial infarction, or heart attack, refers
to the death of a portion of the heart muscle
(myocardium) caused by blood flow
interruption. ST segment elevation refers to
a particular pattern seen on electrocardiogram
(ECG), often seen when a substantial part of
the heart muscle is dying.1
In 2009, approximately 683,000 patients
were discharged from U.S. hospitals with a
diagnosis of acute coronary syndrome (ACS).
Community incidence rates for STEMI have
declined over the past decade, whereas those
for nonST-elevation ACS have increased. At
present, STEMI comprises approximately 25%
to 40% of MI presentations. Approximately
30% of patients with STEMI are women.
Approximately 23% of patients with STEMI in
the United States have diabetes mellitus, and
three quarters of all deaths among patients
with diabetes mellitus are related to coronary
artery disease.3,4
Some of the independent predictors of
early death from STEMI include age, Killip
class, time to reperfusion, cardiac arrest,
tachycardia, hypotension, anterior infarct
location, prior infarction, diabetes mellitus,
smoking status, renal function, and biomarker
findings.5,6
Patients with STEMI do not seek
medical care for approximately 1.5 to 2 hours
after symptom onset, and little change in this
interval has occurred over the past 10 years.
Patient delay times are often longer in women,
blacks, the elderly, and Medicaid-only
recipients and are shorter for Medicare
recipients (compared with privately insured
patients) and patients who are taken directly to
the hospital by emergency medical services
(EMS) transport. Patients may delay seeking
care because their symptoms differ from their
preexisting bias that a heart attack should
present dramatically with severe, crushing
chest pain.7,8
CASE ILLUSTRATION
Mr. ZR, a 47 years-old man who lives in
Prabumulih, came to Mohammad Hoesin
General Hospital on October 30th 2016 with
chief complaint of pain in his upper abdomen
since about five hours before admission.
Since about seven days before
admission, he felt shortness of breath which is
affected by activity and felt better after took
some rest. He slept using two pillows and
often woke up in the middle of the night
because feeling hard to breath, sometimes
nausea was present.
One day before admission, he felt worse
shortness of breath which came even when he
was resting. He could not sleep, felt
palpitation, admitted there were epigastric pain
which radiated to the back and nausea.
Five hours before admission, he felt
severe pain in his upper abdomen as if his
upper abdomen was being squeezed. The pain
last for about half an hour and did not subsided
when he rest. He also felt pain in his back,
nausea and sweaty.
Mr. ZR had first history of simillar pain
attack in 2010 which affected by activity. He
has history of stroke in 2012. He also has
diabetes mellitus and hypertension. There is no
history of hypertension nor diabetes mellitus
from his family.
Based on the patients condition, he was
fully concious, general apperance was
moderately sick with body weight of 87 kg and
height 162 cm, blood preasure 90/60 mmHg,
pulse rate was regular 105 times per minute,
respiratory rate was 30 times per minute, and
body temperature 36,8oC. From physical
examination of the head, we found no
abnormalities in the head, mouth, ears, and
throat. We found the jugular venous preasure
was (5+2) cmH2O and no enlargement of
2
lymph nodes in neck examination. The chest
was symmetrical both in static and dynamic
breathing. Tactile fremitus was symmetric
upon both lungs, on percussion showed that all
fields of both lungs are sonor, vesicular sound
was normal, with wet-smooth ronkhi and
wheezing present in both lungs. Heart
examination showed that ictus cordis was
neither visible nor palpable, upon percussion
showed the upper base of the heart was found
in 2nd ICS, right base was found in 4 th ICS
linea sternalis dextra, and left base was found
in 6th ICS linea axillaris anterior sinistra,
auscultation of the heart showed the heart rate
was 103 times per minute, regular, normal,
M1>M2, T1>T2, A1>A2, P1>P2, neither
murmur nor gallop was heard. Abdominal
examination showed no abnormalities in
inspection, negative shifting dullness and
undulation in percussion, no abdominal
tenderness and no enlargement of the liver nor
spleen in palpation, and normal bowel sounds
present in auscultation. There was no swelling
found in upper and lower extremities, the color
was same as the skin around and cold in upper
and lower extremities. EKG was taken in this
patient and the results were sinus rythm with
left axis and heart rate 102 times per minute.
There was also T inverted in V5-V6, lead I,
and aVL with ST elevation in lead II, III, and
aVF. Cardiac troponin is 1509 ng/mL and
CKMB 31 U/L.
From anamnesis, physical examination,
and additional examination, the patient was
diagnosed with ST elevation myocardial
infarction (STEMI). We differential diagnosis
this patient with unstable angina pectoris
(UAP). From the aspect of the non-
pharmacology, the patient was given oxygen
3-4 L/min, then the patient should use two
pillows when sleep, do bed rest, and learning
the warning symptoms. For the pharmacology
aspect, he was given with aspirin 80 mg/2
hours per oral and clopidogrel 75 mg/2 hours
per oral. Because STEMI is a disease which
there is myocard necrosis caused by sudden
obstruction of coronary vessel and there also a
history of stroke, the patients prognosis for
quo ad vitam is dubia et malam, quo ad
functionam is dubia malam, and quo ad
sanationam is malam.
DISCUSSION
STEMI is a clinical syndrome defined
by characteristic symptoms of myocardial
ischemia in association with persistent
electrocardiographic (ECG) ST elevation and
subsequent release of biomarkers of
myocardial necrosis.2
A STEMI is the most severe of the three
types of Acute Coronary Syndrome (ACS).
ACS occurs when an atherosclerotic
plaque ruptures in a coronary artery. The
rupture causes blood clots to form inside the
artery, which often leads to the partial or
complete occasion of the artery.1
The heart muscle being supplied by the
occluded artery begins to suffer
from ischemia (lack of oxygen), which can
manifest as angina (chest discomfort). If the
blockage is severe enough heart muscle begins
to die, and a myocardial infarction occurs.
Sometimes with ACS, the clot will come and
go over a period of hours or days, without
blocking the artery enough to cause cell death.
This type of ACS is called unstable angina.
Sometimes ACS causes nearly complete
occlusion, but not total occlusion, of the
coronary artery. Cell death occurs, but some of
the heart muscle supplied by the artery
survives. Because the ST segment on the ECG
does not become elevated in this condition, it
is called a non-ST-segment elevation
myocardial infarction, or NSTEMI.1
When the blood clot that forms during
ACS completely blocks the artery, all the heart
muscle supplied by the artery begins to die.
This, the most severe consequence of an ACS,
is called a STEMI. Approximately one third of
patients with MI experience symptoms other
than chest pain.1
Diagnostic STEMI is new ST elevation
at the G-point in at least two continuous leads
of 2mm (0,2 mV) in man or 1,5 mm (0,15
mV) in woman in leads V2/V3 and or of
1mm (0,1 mV) in other continuous chest
leads limb leads. The majority of patients will
3
evolve ECG evidence of Q wave infarction. In
addition ST depression in 2 precordial lead
(V1-V4) may indicate transmural posterior
injury; multilead ST depression with co-
existence ST elevation in lead aVR has been
describe in patient with left main or proximal
left anterior descending artery occlusion.
Rarely, hyperacute T-wave change maybe
observed in the very early phase of STEMI
before the development of ST elevation.2
Clinical manifestation for STEMI are
(1) chest pain which last >20 minutes, (2) pain
which lessen after rest or after nitrate
prescribsion, (3) pain which radiated to below
jaw, neck, left arm or back, and accompanied
by secondary simptoms such as sweating,
nausea, or vomitting.9
Typical chest pain in STEMI is located
in substernal, in the middle or left chest like
heaviness, crushed, or being stab. Another
symptoms are syncope, shortness of breath,
nausea, vomitting,and palpitation. Sometimes
pain is felt in epigastrium and similar to
symptoms of dyspepsia. Uncharacteristic
symptoms often found in woman, elderly, and
patient with diabetic.9
Pharmacology treatment for STEMI are
aspirin 160 mg per oral in addition with
clopidogrel 75 mg per oral. In this case,
dobutamin drip 5 mg in 100 ml natrium
chloride was administered to treat shock and
IV fluid drip Ringer Lactate was givin to
rehirdate the patient.9 Non-pharmacology
treatment are bed rest and oxygen 2-4
L/minute. We suggest percutaneous coronary
intervention using drug eluting stent (DES) to
prevent restenosis.9,10
CONCLUSION
We have discussed a case of epigastric
pain which radiate to the back in a 47 years-
old man. The pain last half an hour and didnt
subsided when he rest. Shortness of breath is
present, accompanied with palpitation and
nausea. The patient has history of stroke in
2012.
REFERENCES
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Acute ST-segment elevation myocardial
infarction: American College of Chest
Physicians Evidence-Based Clinical
Practice Guidelines (8th Edition). Chest
2008; 133:708S.
2. O'Gara PT, Kushner FG, Ascheim DD, et
al. 2013 ACCF/AHA guideline for the
management of ST-elevation myocardial
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the American College of Cardiology
Foundation/American Heart Association
Task Force on Practice Guidelines.
Circulation 2013; 127:529.
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al; Association of bleeding and in-hospital
mortality in black and white patients with
ST-segment-elevation myocardial infarc
tion receiving reperfusion. Circulation.
2012;125:1727-1734.
4. Yeh R.W., Sidney S., Chandra M., et
al; Population trends in the incidence and
outcomes of acute myocardial infarction. N
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5. Van de Werf F., Bax J., Betriu A., et
al; Management of acute myocardial
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persistent ST-segment elevation: the Task
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the European Society of Cardiology. Eur
Heart J. 2008;29:2909-2945.
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al; The impact of anthropomorphic indices
on clinical outcomes in patients with acute
ST-elevation myocardial infarction. Eur
Heart J. 2007;28:415-424.
7. Goldberg R.J., Spencer F.A., Fox K.A.A.,
et al; Prehospital delay in patients with
acute coronary syndromes (from the Global
Registry of Acute Coronary Events
[GRACE]). Am J Cardiol. 2009;103:598-
603.
8. Spencer F.A., Montalescot G., Fox
K.A.A., et al; Delay to reperfusion in
patients with acute myocardial infarction
presenting to acute care hospitals: an
international perspective. Eur Heart J.
2010;31:1328-1336.
9. Sally AN; Sindrom koroner akut dengan
peningkatan segmen ST. EIMED PAPDI
Kegawatdaruratan Penyakit Dalam Buku
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10.Dafsah J, Irmalita;Sindrom koroner akut.
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